HospitalInspections.org

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

1) Failing to ensure all medication orders (except in emergency situations) were reviewed for appropriateness by a pharmacist prior to the first dose being dispensed and/or administered to the patient. (cross reference findings cited at A0500)

2) Failed to ensure that medications are dispensed in a timely manner by failing to have an effective system in place to ensure the medication orders get to the pharmacy and medications get back to patients promptly so the medications can be administered as ordered. Medication errors were noted in the medical records of 4 of 9 patients (#1, #14, #17, #21), whose medical records were reviewed for administration of medications out of a total sample of 33 patients. (cross reference findings cited at A0501)

3) Failing to ensure drug administration errors were identified and immediately reported to the patient's attending physician/practitioner. This failure to identify and report medication errors resulted in the physician/practitioner being unaware that medications were not administered as ordered and resulted in the hospital's inability to ensure corrective action and/or interventions were implemented to reduce medication errors and/or adverse reactions. (cross reference findings cited at A0508)

4) Failing to ensure a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs. (cross reference findings cited at A0511)

5) Failing to ensure all facilities, supplies, and equipment were maintained to to ensure an acceptable level of safety and quality. (cross reference findings cited at A0724)

6) Failing to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced by having outdated Infection Control policies and procedures for isolation precautions (CDC guidelines, 1997). (cross reference findings cited at A0748)

7) Failing to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced by having outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004). (cross reference findings cited at A0748)

8) Failing to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced having the information, knowledge and capability to update the manuals but failed to do so. (cross reference findings cited at A0748)

9) Failing to ensure the Infection Control Officer, (S4ICN) developed a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by:
a) having the rate of Hospital Acquired Infections (HAIs) of 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 of 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 of 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011 as of 5/26/11,
b) identifying patients with organisms that were not present upon admission and these organisms requiring mandated institution of contact precautions as indicated on the laboratory culture results for Patient #1, #3, #4, #6, #7, #10, #11, #12, #14, #16 for 10 of 10 sampled patients records focused for isolation precaution out of a total of 33 sampled patients. (cross reference findings cited at A0749)

An immediate jeopardy situation was identified on 5/23/11 at 2:40 p.m. and was reported to the Administrator, (S1), Director of Nursing (DON, S2), and Infection Control Nurse, (ICN, S4LPN). The immediate jeopardy situation was a result of:

The hospital failed to ensure the safety of patients and staff members within the hospital by failing to have a system in place to ensure compliance with CDC Guidelines relating to patients placed on specialized precautions including contact precautions and respiratory precautions. This failure is likely to cause serious injury and/or harm to a patient and/or staff member as a high risk for cross contamination exists.

An observation conducted on 5/17/11 revealed 6 patients' (#1, #3, #4, #5, #6, #11) doors had a sign reading "Contact Precautions" and one patient's (#2) door had a sign "Respiratory Isolation" out of a total of 17 patients. During this observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview with the staff members (2 LPNs and 1 CNA) revealed the one cart was to be used for all 6 patients on "Contact Precautions" and the 1 patient on "Respiratory Isolation." Further observation revealed a nursing staff member entering Patient #11 ' s room without applying the personal protective equipment as stated in the "Protective Isolation" Policy. A second observation of housekeeping staff revealed the staff member mopping Patient #11's room with the door open and she was not wearing the personal protective equipment as per the Housekeeping policies for Isolation Precautions. Another observation revealed two patients (#3, #4) identified by the hospital as requiring contact precautions were out of their rooms without personal protective equipment. Record review revealed there were 4 patients (#7, #12, #14, #16) whose laboratory findings included Multi-Drug Resistant Organisms (MDRO). According to Center for Disease Control (CDC) Guidelines (2006), contact precautions are mandated for these MDROs. Further observations revealed these 4 patients were not placed on contact precautions from 5/17/11 through 5/18/11.
Record review of the QA minutes revealed the hospital ' s Infection Control Nurse identified the rate of Hospital Acquired Infections (HAI) was 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 was 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 was 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011. Further investigation into the type of organisms, which required contact precautions as mandated by CDC (2006) revealed the following: In January, the MDRO identified included Acinetobacter baumannil complex, Escherichia coli (E. coli), Methicillin resident Staphlococcus aureas (MRSA), a Vancomycin Resistant Enterococcus faecalis (VRE), and Clostridium difficile. In February, the MDRO identified included Staphlococcus epidermis, Clostridium difficile, MRSA, Klebsiella pneumoniae, Strep agalactiae, Group B, Acinetobactor baumannil complex, and Enterococcus faecalis. In March, the MDRO identified included Acinetobacter Baumannil complex, Klebsiella pneumoniae, MRSA, VRE, and Clostridium difficle. In April, the MDRO identified included: Klebsiella pneumoniae, VRE, Acinetobacter baumannil complex, MRSA, Group B Streptococcus, Streptococcus agalactiae Group B, Clostridium difficle, and Escherichia coli.
Record review of the hospital's infection control policies and procedures for isolation precautions (CDC Guidelines,1997) and Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions (Hospital policies, 2000) were not revised to reflect the current CDC 2006 Guidelines on how to manage hospital acquired infections.
A plan of removal (POR) #2 was submitted on 5/25/11 at 09:46 a.m. and plan of removal (POR) #3 was submitted on 5/25/11 at 3:55 p.m.. The corrective action plan for POR #2 included the following:

"5/24/11 Community Specialty Hospital Time Line of Correction:
1. Infection Control Nurse Consultant hired. She worked 05/24/11 and will be available as needed.
2. The Director of Nurses, Infection Prevention Nurse and the consultant went through all the charts and looked at the lab values and cultures.
3. They determined who was on which precautions and identified them by signs on doors and charts.
4. An emergency in-service was called 05/24/11 and staff in-service is attached. One hundred percent of staff will be in-serviced by 06/06/11. Staff will not be allowed to work at hospital until they receive an in-service.
5. Policies are being reviewed and revised as specified by the CDC.
6. An emergency meeting of the Governing Body and MEC will be held on 05/27/11 to approve any new policies.
7. All patients needing to be isolated will be educated. It will be documented in the patient chart by 05/26/11.
8. A new Q/A sheet for Infection Control has been developed and will be implemented 05/25/11.
9. Daily surveillance will be initiated 05/25/11 by Infection Prevention and DON.
10. 05/25/11 all new hires will be given inservice agenda. DON will orientate all new hires regarding infection control
11. 05/25/11 annual inservice on infection control will be done annually."

The corrective action plan for POR #3 included the following:
"May 25, 2011 3:30 PM Community Specialty Hospital effective immediately will adopt 2007 CDC guidelines. The hospital will assure that 2007 CDC guidelines are followed.
In-services for 100% of staff will begin immediately on this shift and will continue until next shift and will follow thereafter before beginning patient care."

As a result of the hospital's action plan, the Immediate Jeopardy situation was lifted at 4:20 p.m. on 05/25/11.

10) Failing to ensure the Infection Control Officer, (S4ICN) developed a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by
failing to have a system in place for active surveillance of staff practices of asepsis, correct use of PPE, correct use of isolation precautions, proper cleaning of equipment as evidenced by:
a) failing to have documented evidence of monitoring and evaluating handwashing procedures from November of 2010 through 5/26/11,
b) failing to have staff members (S3CNA, S6Housekeeping) wear personal protective equipment (PPE) before entering a patient ' s room and remove the PPE before leaving the patient room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation", and
c) failing to have a policy available for staff to provide isolation precautions as ordered by the attending physician for "Contact Precaution" for 7 of 7 patients on 5/17/11, (#1, #3, #4, #5, #6, #11) and "Respiratory Isolation" for 1 of 1 patient, (#2) out of a total of 17 patients in the facility on 5/17/11 and for 9 of 9 patients on 5/18/11, (#1, #3, #4, #6, #8, #11, #12, #14, #16) and one patient (#2) on "Respiratory Isolation" out of a total of 18 patients in the facility on 5/18/11. (cross reference findings cited at A0749)

11) Failing to ensure the Infection Control Officer, (S4ICN) developed, revised, and updated the Infection Control Programs Policies and Procedures annually and as necessary as per policy as evidenced by:
a) having outdated 1997 CDC Guidelines in the current Infection Control binder,
b) having no policy regarding Multi-drug Resistant Organisms (MDRO), Contact Precaution, and/or Respiratory Isolation in the current Infection Control Manual,
c) having incorrect isolation policies (General Policies for Isolation, Gowning and Masks; Miscellaneous Isolation Precautions; Body Substance Isolation) with 1997 CDC Guidelines to be followed for the 12 of 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified on 5/17/11 and 5/18/11 that were on " Contact Precaution " and/or "Respiratory Isolation",
d) having poor infection control practices performed by the staff as evidenced by staff members (S3CNA, S6Housekeeping) not wearing personal protective equipment (PPE) before entering a patients' room and removing the PPE before leaving the patients ' room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation",
e) having no education of staff and patients regarding the diseases/organisms identified as HAIs in January, February, and March of 2011 as evidenced by having outdated 1997 CDC Guidelines, incorrect Isolation Precaution policies, or established policies for Contact Precaution, Respiratory Isolation or Multi-drug Resistant Organism for the staff providing direct patient care for the 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified during the survey on 5/17/11 and 5/19/11 that were on "Contact Precaution" and/or "Respiratory Isolation",
f) having improper cleaning of patient equipment with " Buckeye Sanicare Lemon Quat " disinfectant cleaner for the bedbound patients by staff not following the special protection (glasses or goggles, rubber gloves or other impervious gloves, maintain adequate ventilation, avoid breathing spray mist, wash thoroughly with soap and water after handling, remove contaminated clothing, and wash clothing before reuse) and special precautions (Do not contaminate water, food or feed by storage or disposal) on the Material Safety Data Sheet, (MSDS) to be implemented and followed while using the cleanser, and
g) having outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004). (cross reference findings cited at A0395, A0749)

12) Failing to ensure the Infection Control Officer, (S4ICN) developed a system for identified and prevented infectious diseases/organisms in the hospital as evidenced by
failing to ensure all staff providing direct patient care had Tuberculin (TB) Test results administered and interpreted in 48 to 72 hours as per policy for 7 of 7 personnel files reviewed for TB Test Screening, (S2DON, S3CNA, S8RN, S15LPN, S18CNA, S28LPN, S29LPN) and for 7 of 7 Credentialing Files, (S7PA, S20MD, S21MD, S22MD, S23MD, S24MD, S25MD, S26MD, S27MD). (cross reference findings cited at A0749)

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

1) Failed to ensure all facilities, supplies, and equipment were maintained to to ensure an acceptable level of safety and quality. (See findings cited at A0724)

2) Failed to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced by having outdated Infection Control policies and procedures for isolation precautions (CDC guidelines, 1997). (See findings cited at A0748)

3) Failed to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced by having outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004). (See findings cited at A0748)

4) Failed to ensure the Infection Control Officer, (S4ICN) developed and implemented policies governing the control of Healthcare Associated Infections (HAIs) as evidenced having the information, knowledge and capability to update the manuals but failed to do so. (See findings cited at A0748)

5) Failed to ensure the Infection Control Officer, (S4ICN) developed a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by:
a) having the rate of Hospital Acquired Infections (HAIs) of 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 of 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 of 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011 as of 5/26/11,
b) identifying patients with organisms that were not present upon admission and these organisms requiring mandated institution of contact precautions as indicated on the laboratory culture results for Patient #1, #3, #4, #6, #7, #10, #11, #12, #14, #16 for 10 of 10 sampled patients records focused for isolation precaution out of a total of 33 sampled patients. (See findings cited at A0749)

An immediate jeopardy situation was identified on 5/23/11 at 2:40 p.m. and was reported to the Administrator, (S1), Director of Nursing (DON, S2), and Infection Control Nurse, (ICN, S4LPN). The immediate jeopardy situation was a result of:

The hospital failed to ensure the safety of patients and staff members within the hospital by failing to have a system in place to ensure compliance with CDC Guidelines relating to patients placed on specialized precautions including contact precautions and respiratory precautions. This failure is likely to cause serious injury and/or harm to a patient and/or staff member as a high risk for cross contamination exists.

An observation conducted on 5/17/11 revealed 6 patients' (#1, #3, #4, #5, #6, #11) doors had a sign reading "Contact Precautions" and one patient's (#2) door had a sign "Respiratory Isolation" out of a total of 17 patients. During this observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview with the staff members (2 LPNs and 1 CNA) revealed the one cart was to be used for all 6 patients on "Contact Precautions" and the 1 patient on "Respiratory Isolation." Further observation revealed a nursing staff member entering Patient #11's room without applying the personal protective equipment as stated in the "Protective Isolation" Policy. A second observation of housekeeping staff revealed the staff member mopping Patient #11's room with the door open and she was not wearing the personal protective equipment as per the Housekeeping policies for Isolation Precautions. Another observation revealed two patients (#3, #4) identified by the hospital as requiring contact precautions were out of their rooms without personal protective equipment. Record review revealed there were 4 patients (#7, #12, #14, #16) whose laboratory findings included Multi-Drug Resistant Organisms (MDRO). According to Center for Disease Control (CDC) Guidelines (2006), contact precautions are mandated for these MDROs. Further observations revealed these 4 patients were not placed on contact precautions from 5/17/11 through 5/18/11.
Record review of the QA minutes revealed the hospital's Infection Control Nurse identified the rate of Hospital Acquired Infections (HAI) was 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 was 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 was 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011. Further investigation into the type of organisms, which required contact precautions as mandated by CDC (2006) revealed the following: In January, the MDRO identified included Acinetobacter baumannil complex, Escherichia coli (E. coli), Methicillin resident Staphlococcus aureas (MRSA), a Vancomycin Resistant Enterococcus faecalis (VRE), and Clostridium difficile. In February, the MDRO identified included Staphlococcus epidermis, Clostridium difficile, MRSA, Klebsiella pneumoniae, Strep agalactiae, Group B, Acinetobactor baumannil complex, and Enterococcus faecalis. In March, the MDRO identified included Acinetobacter Baumannil complex, Klebsiella pneumoniae, MRSA, VRE, and Clostridium difficle. In April, the MDRO identified included: Klebsiella pneumoniae, VRE, Acinetobacter baumannil complex, MRSA, Group B Streptococcus, Streptococcus agalactiae Group B, Clostridium difficle, and Escherichia coli.
Record review of the hospital's infection control policies and procedures for isolation precautions (CDC Guidelines,1997) and Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions (Hospital policies, 2000) were not revised to reflect the current CDC 2006 Guidelines on how to manage hospital acquired infections.
A plan of removal (POR) #2 was submitted on 5/25/11 at 09:46 a.m. and plan of removal (POR) #3 was submitted on 5/25/11 at 3:55 p.m.. The corrective action plan for POR #2 included the following:

"5/24/11
Community Specialty Hospital Time Line of Correction:
1. Infection Control Nurse Consultant hired. She worked 05/24/11 and will be available as needed.
2. The Director of Nurses, Infection Prevention Nurse and the consultant went through all the charts and looked at the lab values and cultures.
3. They determined who was on which precautions and identified them by signs on doors and charts.
4. An emergency in-service was called 05/24/11 and staff in-service is attached. One hundred percent of staff will be in-serviced by 06/06/11. Staff will not be allowed to work at hospital until they receive an in-service.
5. Policies are being reviewed and revised as specified by the CDC.
6. An emergency meeting of the Governing Body and MEC will be held on 05/27/11 to approve any new policies.
7. All patients needing to be isolated will be educated. It will be documented in the patient chart by 05/26/11.
8. A new Q/A sheet for Infection Control has been developed and will be implemented 05/25/11.
9. Daily surveillance will be initiated 05/25/11 by Infection Prevention and DON.
10. 05/25/11 all new hires will be given inservice agenda. DON will orientate all new hires regarding infection control
11. 05/25/11 annual inservice on infection control will be done annually. "

The corrective action plan for POR #3 included the following:
"May 25, 2011 3:30PM Community Specialty Hospital effective immediately will adopt 2007 CDC guidelines. The hospital will assure that 2007 CDC guidelines are followed.
In-services for 100% of staff will begin immediately on this shift and will continue until next shift and will follow thereafter before beginning patient care."

As a result of the hospital's action plan, the Immediate Jeopardy situation was lifted at 4:20 p.m. on 05/25/11. The deficiency remained at a condition level.

6) Failed to ensure the Infection Control Officer, (S4ICN) developed a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by
failing to have a system in place for active surveillance of staff practices of asepsis, correct use of PPE, correct use of isolation precautions, proper cleaning of equipment as evidenced by:
a) failing to have documented evidence of monitoring and evaluating handwashing procedures from November of 2010 through 5/26/11,
b) failing to have staff members (S3CNA, S6Housekeeping) wear personal protective equipment (PPE) before entering a patient's room and remove the PPE before leaving the patient room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation", and
c) failing to have a policy available for staff to provide isolation precautions as ordered by the attending physician for "Contact Precaution" for 7 of 7 patients on 5/17/11, (#1, #3, #4, #5, #6, #11) and "Respiratory Isolation" for 1 of 1 patient, (#2) out of a total of 17 patients in the facility on 5/17/11 and for 9 of 9 patients on 5/18/11, (#1, #3, #4, #6, #8, #11, #12, #14, #16) and one patient (#2) on "Respiratory Isolation" out of a total of 18 patients in the facility on 5/18/11. (See findings cited at A0395, A0749)

7) Failed to ensure the Infection Control Officer, (S4ICN) developed, revised, and updated the Infection Control Programs Policies and Procedures annually and as necessary as per policy as evidenced by:
a) having outdated 1997 CDC Guidelines in the current Infection Control binder,
b) having no policy regarding Multi-drug Resistant Organisms (MDRO), Contact Precaution, and/or Respiratory Isolation in the current Infection Control Manual,
c) having incorrect isolation policies (General Policies for Isolation, Gowning and Masks; Miscellaneous Isolation Precautions; Body Substance Isolation) with 1997 CDC Guidelines to be followed for the 12 of 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified on 5/17/11 and 5/18/11 that were on "Contact Precaution" and/or "Respiratory Isolation",
d) having poor infection control practices performed by the staff as evidenced by staff members (S3CNA, S6Housekeeping) not wearing personal protective equipment (PPE) before entering a patient's room and removing the PPE before leaving the patients ' room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation",
e) having no education of staff and patients regarding the diseases/organisms identified as HAIs in January, February, and March of 2011 as evidenced by having outdated 1997 CDC Guidelines, incorrect Isolation Precaution policies, or established policies for Contact Precaution, Respiratory Isolation or Multi-drug Resistant Organism for the staff providing direct patient care for the 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified during the survey on 5/17/11 and 5/19/11 that were on "Contact Precaution" and/or "Respiratory Isolation",
f) having improper cleaning of patient equipment with "Buckeye Sanicare Lemon Quat" disinfectant cleaner for the bedbound patients by staff not following the special protection (glasses or goggles, rubber gloves or other impervious gloves, maintain adequate ventilation, avoid breathing spray mist, wash thoroughly with soap and water after handling, remove contaminated clothing, and wash clothing before reuse) and special precautions (Do not contaminate water, food or feed by storage or disposal) on the Material Safety Data Sheet, (MSDS) to be implemented and followed while using the cleanser, and
g) having outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004). (See findings cited at A0749)

8) Failed to ensure the Infection Control Officer, (S4ICN) developed a system for identified and prevented infectious diseases/organisms in the hospital as evidenced by
failing to ensure all staff providing direct patient care had Tuberculin (TB) Test results administered and interpreted in 48 to 72 hours as per policy for 7 of 7 personnel files reviewed for TB Test Screening, (S2DON, S3CNA, S8RN, S15LPN, S18CNA, S28LPN, S29LPN) and for 7 of 7 Credentialing Files, (S7PA, S20MD, S21MD, S22MD, S23MD, S24MD, S25MD, S26MD, S27MD). (See findings cited at A0749)




26313

Based on record reviews and interviews, the hospital's governing body failed to ensure that contracted pharmacy services were provided in a manner to permit the hospital to comply with all applicable conditions of participation and standards for contracted services as evidenced by:

1. The hospital's failure to ensure that medications were dispensed in a timely manner by failing to have an effective system in place to ensure that medication orders get to the pharmacy and medications get back to patients promptly so that the medications can be administered as ordered. (cross reference to findings cited at A0501)

2. The hospital's failure to ensure that drug administration errors were identified and immediately reported to the patient's attending physician/practitioner. This failure to identify and report medication errors resulted in the physician/practitioner being unaware that medications were not administered as ordered and resulted in the hospital's inability to ensure that corrective action and/or interventions were implemented to reduce medication errors and/or adverse reactions. (cross reference to findings cited at A0508)

3. The hospital's failure to ensure that all medication orders (except in emergency situations) were reviewed for appropriateness by a pharmacist prior to the first dose being dispensed and/or administered to the patient. (cross reference to findings cited at A0500)

4. The hospital's failure to ensure that a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs. (cross reference to findings cited at A0511)

Based on record reviews and interviews, the Governing Body failed to have appropriate policies and procedures in place to address patient emergencies as evidenced by having an Emergency Care Protocol that directed nursing staff to administer D50 (concentrated glucose) to all patients found unconscious. This had the potential to affect all patients. Findings:

Review of the the hospital's Emergency Care Protocol, approved 07-10-09, last revised 08-14-09, reads in part: " Policy: "Hospital" does not provide physician services on-site 24 hours a day and does not provide an Emergency Department. It is the policy of this hospital to conduct appraisals, render initial treatment and transfer the patient when the patient's clinical condition exceeds the capabilities of "Hospital." Procedure: In a presenting emergency situation, the following is to be done concurrently in coordination with staff as assigned by the RN. 9-1-1 is called to initiate the emergency response for transfer. The facility does have an AED (automated external defibrillator). The RN is to assess the patient in all presenting emergency situations and the MD (on-site or on call) is notified immediately to give orders for initial stabilizing treatment, to provide medical oversight and to order the transfer by ambulance. Upon entering the room the following is to be prioritized: 1. Establish consciousness. If unconscious: Administer D50 (concentrated dextrose solution) 1 Amp (ampule) IV (intravenous). Check CBG (capillary blood glucose)."

Review of the 2011 Drug Handbook (Lippincott, Williams, and Wilkins) presented as the resource available to nurses as a medication reference revealed the following: "Dextrose. Contraindications: Contraindicated in patients in diabetic coma while glucose remains excessively high ...contraindicated in patients with intracranial hemorrhage ..."

In an interview on 05/24/11 at 9:15 a.m. with S2DON, he confirmed the 2011 Drug Handbook (Lippincott, Williams, and Wilkins) was the drug reference available to nursing staff and the Emergency Care Protocol, approved 07-10-09, last revised 08-14-09, was the current Emergency Care Protocol available to nursing staff. S2DON stated that, as written, he would not follow the policy because the unconscious patient could be hyperglycemic. S2DON reviewed the drug reference available to nurses and confirmed that contraindications to administration of D50 included hyperglycemia and intracranial hemorrhage. S2DON further confirmed the policy directs nursing to administer D50 prior to checking the patient's blood glucose or assessing for signs/symptoms of intracranial hemorrhage. This has the potential to cause further harm to the patient.

In an interview on 05/25/11 at 8:40 a.m. with S22MD, Medical Director, he read the policy and stated he would not expect the policy to be followed as written. S22MD stated the policy needs to be changed as to not direct all unconscious patients to be given D50 1 Ampule IV(intravenous).

Review of the Governing Body By-Laws Article IV under Responsibilities revealed "...C. The Governing Body shall hold the Hospital Administration responsible for reviewing and/or revising all hospital policies and procedures annually or as needed."

Based on observations, record reviews and staff interviews, the hospital failed to ensure the Registered Nurse supervised and evaluated the nursing care for each patient on "Contact Precaution" and/or "Respiratory Isolation" as evidenced by:
1) failing to ensure the hospital staff members wore personal protective equipment while providing direct care to patients observed with isolation precautions posted on the door for 2 of 7 patients observed with isolation precaution signs posted on the doors, (#2, #11) out of a total of 17 patients on the unit on 5/17/11;
2) failing to ensure all patients remained in the rooms and/or wore personal protective equipment while out of the room for 2 of 7 patients, (#3, #4) observed with "Contact Precaution" signs posted on the outside of the patient's doors out of a total of 17 patients on the unit on 5/17/11 and 1 of 5 patients, (#10) out of a total of 18 patients on the unit on 5/23/11;
3) failing to ensure the laboratory culture results indicating "Contact Precautions" were implemented by all staff providing direct patient care for 5 of 9 sampled patients focused for isolation precautions out of a total of 18 patients, (#7, #10, #12, #14, #16); and
4) failing to ensure all patients were assessed every 24 hours as per policy for 5 of 5 sampled medical records focused for daily RN assessments out of a total of 33 sampled patient records reviewed, (Patient #2, #7, #12, #14, #16).
Findings:

1)
Observations conducted on 5/17/11 at 12:05 p.m. and 4:40 p.m., revealed six (6) patients' (#1, #3, #4, #5, #6, #11) doors had a sign reading, "Contact Precautions" and one (1) patient's (#2) door had a sign reading, "Respiratory Isolation" out of a total of 17 patients that were on the unit on 5/17/11. During this same observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview was conducted at this time with S3CNA, she confirmed there was one cart available on the unit that was to be used for all 6 patients (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on Respiratory Isolation.

In interviews with the staff members (S28LPN, S29LPN, S2DON) conducted on 5/17/11 at 4:20 p.m., they all verified there was one cart available on the unit that was being used for all 6 patients (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on Respiratory Isolation.

Another observation conducted on 5/17/11 at 12:30 p.m. revealed a staff member, (S3CNA) entered Patient #11's room without applying the personal protective equipment as stated in the "Protective Isolation" policy. A second observation conducted at 12:35 p.m. revealed a staff member (S38CNA) walked to Patient #11's room with a wash cloth in her right gloved hand. Further observation conducted on 5/18/11 at 8:00 a.m. revealed a housekeeping staff member, (S6) was mopping the floor inside Patient #11's room without wearing personal protective equipment and/or gloves as indicated in the Housekeeping policies for "Isolation Precautions".

Review of the hospital ' s current Nursing and Infection Control policy and procedure manuals revealed there were no current policy regarding " Contact Precaution " , " Respiratory Isolation " and/or "Multi-Drug Resistant Organisms" presented during the survey from 5/17/11 through 5/26/11.

2)
Patient #3 and Patient #4:
During a tour of the facility conducted on 5/17/11 at 4:10 p.m., Patient #3's and Patient #4's doors were both observed with a sign reading, "Contact Precautions". Further observation revealed both patients (#3, #4) were not in their rooms at this time. At 4:30 p.m., Patient #4 was observed sitting in his wheelchair wheeling himself down the hallway back to his room and he was not wearing personal protective equipment at this time. Further observation revealed Patient #3 was sitting in his wheelchair watching TV (television) in an area by the nursing station with no personal protective equipment noted at this time.

On 5/17/11 at 4:20 p.m., at 4:30 p.m., at 4:35 p.m., and at 4:40 p.m., S2, Director of Nursing (DON) verified Patient #3 and Patient #4 were both on "Contact Precaution" as indicated on the signs posted on the patient's doors. The DON indicated all patients on "Contact Precaution" should remain in the room at all times as per policy. S2 stated that both patients (#3, #4) were both out of their rooms as per policy. S2DON indicated both patients (#3, #4) should be wearing personal protective equipment while out of the room.

Patient #10:
During another observation of the unit on 5/23/11 at 1:55 p.m., the patient was observed sitting in a wheelchair across from the nursing station with the foley catheter tubing touching the floor about one foot in length. Further observation revealed the patient was not wearing personal protective equipment while out of his room. At this same time, S14RN, Charge Nurse confirmed the patient was out of his room with no personal protective equipment as per policy. S14RN, Charge Nurse indicated the "Contact Precaution" policy indicates all patients must remain in the room at all times.

Review of the patient's urine culture collected on 5/19/11 at 04:30 (4:30 a.m.), verified on 5/22/11 at 08:27 (8:27 a.m.) revealed the urine had Providencia Stuartii organism that mandates the institution of contact precautions. Further review revealed there was no documentation of Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours.

On 5/23/11 at 3:00 p.m., S2DON confirmed there was no sign posted on the patient's door by the Registered Nurse/Charge Nurse as per policy for all patients on "Contact Precaution" mandated by the urine lab resulted this morning (5/23/11) at 8:27 a.m. S2 verified there was no documentation the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours as per protocol.

3)
Another observation of the unit was conducted on 5/18/11 from 8:05 a.m. through 8:30 a.m. with S5RN, Charge Nurse revealed there were no "Contact Precaution" signs posted on the outside door for Patient #7, #12, #14 or #16 observed during this observation. At this time, S5RN confirmed the patients (#7, #12, #14, #16) did not have a sign reading, "Contact Precaution" posted on the outside of the patient's doors. S5 verified Patient #7's, #12's, #14's and #16's laboratory culture results mandated institution of "Contact Precautions". S5RN reported the patients (#7, #12, #14, #16) should all have a sign posted on the outside of the door indicating "Contact Precaution" must be implemented by all staff providing direct patient care as per policy. S5RN stated there was no system in place for the Registered Nurse to mandate the institution of "Contact Precaution" measures for the patient and staffs to prevent cross contamination of all staff providing direct patient care. S5RN reported all patients with laboratory culture results mandating "Contact Precaution" measures should be implemented by all staff the same day that the culture is collected until the final culture results come back. S5 stated "Contact Precaution" measures must be maintained by all staff providing direct patient care after the lab result indicates the mandating of contact precaution until the physician discontinues. S5 continued the final lab result mandating "Contact Precaution" instituted must be adhered by all staff providing direct patient care to prevent cross contamination from one patient to another. S5RN indicated all staff wear personal protective equipment (gloves, gowns and masks) prior to entering the patient's room, remove them (personal protective equipment) in the patient's room after providing direct patient care, and perform handwashing prior to leaving the patient's room for all patients identified on "Contact Precaution" and/or "Respiratory Isolation" in order to prevent cross contamination from one patient to another. S5RN indicated no personal protective equipment (gloves, gowns, and/or masks) should be worn out of a patient's room if a patient is on "Contact Precaution" and/or "Respiratory Isolation".

Patient #7:
Review of the patient's sacrum wound culture collected on 5/5/11 at 14:25 (2:25 p.m.) and verified on 5/7/11 at 07:57 (7:57 a.m.) revealed the wound had Proteus mirabalis organism that mandates the institution of contact precautions. Further review revealed there was no documented evidence that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/5/11 through 5/18/11 for about 13 days. Review of the patient's mediport blood culture collected on 5/9/11 at 18:15 (6:15 p.m.) and verified on 5/10/11 at 21:00 (9:00 p.m.) revealed MRSA organism that mandates the institution of contact precautions. Further review revealed there was no documentation of "Contact Precaution" measures were implemented by the Registered Nurse/Charge Nurse for about 9 days.

On 5/18/11 at 8:15 a.m., the Director of Nursing, (DON, S2) verified Patient #7 did not have a "Contact Precaution" sign posted on the outside of the door. S2DON verified Patient #7's sacrum wound culture collected on 5/5/11 revealed the wound had Proteus mirabalis organism. S2 indicated the lab result indicated "Contact Precaution" measures were mandated. The DON confirmed there was no sign posted on the patient's door indicating "Contact Precaution" measures were being implemented by all staff providing direct patient care. He verified there was no documented evidence of the staff providing the patient direct care implementing "Contact Precaution" measures from 5/5/11 through 5/18/11 for about 13 days. S2 indicated the Registered Nurse/Charge Nurse (S5RN) did not implement the "Contact Precaution" measures to post a sign on the patient's door as per policy. S2DON verified the patient's mediport culture had MRSA identified on 5/9/11. S2 confirmed there was no documentation of "Contact Precaution" measures being implemented by the Registered Nurse as per policy for about 9 days.

Patient #10:
Review of the patient's urine culture collected on 5/19/11 at 04:30 (4:30 a.m.), verified on 5/22/11 at 08:27 (8:27 a.m.) revealed the urine had Providencia Stuartii organism that mandates the institution of contact precautions. Further review revealed there was no documentation of Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours.

On 5/23/11 at 3:00 p.m., S2DON confirmed there was no sign posted on the patient's door by the Registered Nurse/Charge Nurse as per policy for all patients on "Contact Precaution" mandated by the urine lab resulted this morning (5/23/11) at 8:27 a.m. S2 verified there was no documentation the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours as per protocol.

Patient #12:
Review of the patient's left Ischium culture collected on 5/4/11 at 09:30 (9:30 a.m.) and verified on 5/8/11 at 08:21 (8:21 a.m.) revealed the Ischium had Proteus mirabilis, Klebsiella pneumoniae, Enterococcus faecalis and Methicillin Resistant Staph aureus (MRSA) organisms. The Proteus mirabilis, Klebsiella and MRSA all mandates the institution of contact precautions. Further review revealed there was no documentation that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/4/11 to 5/18/11 for about 14 days. Review of the patient's urine clean catch culture collected on 5/6/11 at 04:30 (4:30 a.m.) and verified on 5/9/11 at 08:27 (8:27 a.m.) revealed the urine had Acinetobacter baumannii complex organism that mandates the institution of contact precautions. Further review revealed there was no documented evidence the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/6/11 through 5/18/11 for approximately 12 days.

On 5/18/11 at 8:15 a.m., the Director of Nursing, (DON, S2) verified Patient #12 did not have a "Contact Precaution" sign posted on the outside of the door. S2DON reviewed the Patient #12's left Ischium culture collected on 5/4/11 at 09:30 (9:30 a.m.) and verified on 5/8/11 at 08:21 (8:21 a.m.) revealed the Ischium had Proteus mirabilis, Klebsiella pneumoniae, Enterococcus faecalis and Methicillin Resistant Staph aureus (MRSA). The DON indicated the Ischium culture result indicated "Contact Precaution" were mandated. S2 verified there was no documentation that the nurse implemented "Contact Precaution" measures as indicated on the lab results from 5/4/11 to 5/18/11 for about 14 days. The DON reviewed the patient's urine clean catch culture collected on 5/6/11 at 04:30 (4:30 a.m.) and verified on 5/9/11 at 08:27 (8:27 a.m.) indicated the urine had Acinetobacter baumannii complex organism. S2 indicated the urine culture mandates the institution of "Contact Precautions" as per policy. S2DON stated there was no documented evidence that the nurse implemented "Contact Precaution" measures as indicated on the urine lab result from 5/6/11 through 5/18/11 for approximately 12 days.

Patient #14:
Review of the patient's sacrum culture collected on 5/15/11 at 17:16 (5:16 p.m.), verified on 5/18/11 at 08:11 (8:11 a.m.) revealed the sacrum had Proteus mirabilis, Klebsiella pneumoniae, and Methicillin Resistant Staph aureus (MRSA) organisms all mandates the institution of contact precautions. Further review revealed there was no documentation that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/15/11 through 5/18/11 for approximately 3 days.

In the same interview on 5/18/11 at 8:15 a.m., S2DON confirmed Patient #14 did not have a "Contact Precaution" sign posted on the outside of the door. S2 verified Patient #14's sacrum culture collected on 5/15/11 at 17:16 (5:16 p.m.), verified on 5/18/11 at 08:11 (8:11 a.m.) revealed it had Proteus mirabilis, Klebsiella pneumoniae, and Methicillin Resistant Staph aureus (MRSA) organisms. S2 indicated the sacrum culture result mandated "Contact Precaution" measures to be implemented. The DON indicated there was no documentation that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures as indicated on the lab results from 5/15/11 through 5/18/11 for approximately 3 days as per policy.

Patient #16:
Review of the patient's left Hip culture collected on 4/29/11 at 07:40 (7:40 a.m.) and verified on 5/3/11 at 08:58 (8:58 a.m.) revealed the Hip had Proteus mirabilis and Escherichia coli organisms both mandates the institution of contact precautions. Further review revealed there was no documented evidence the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures were implemented from 4/29/11 to 5/18/11 for about 19 days. Review of the patient's mediport culture collected on 5/6/11 at 12:20 (12:20 p.m.) and verified on 5/8/11 at 07:59 (7:59 a.m.) revealed the mediport had Methicillin Resistant Staph aureus (MRSA) organism that mandates the institution of contact precautions. Further review revealed there was no documentation of the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/6/11 through 5/18/11 for about 12 days.

S2DON was interviewed during the same interview conducted on 5/18/11 at 8:15 a.m. The DON verified Patient #16 did not have a "Contact Precaution" sign posted on the outside of the door. S2 reviewed the patient's left Hip culture collected on 4/29/11 at 07:40 (7:40 a.m.), verified on 5/3/11 at 08:58 (8:58 a.m.) and revealed the Hip had Proteus mirabilis and Escherichia coli organisms. S2 indicated the hip laboratory result indicated mandate institution of "Contact Precaution". The DON indicated there was no documented evidence the nurse implemented "Contact Precaution" measures as indicated on the lab results from 4/29/11 to 5/18/11 for about 19 days as per policy. S2DON reviewed the patient's mediport culture collected on 5/6/11 at 12:20 (12:20 p.m.), verified on 5/8/11 at 07:59 (7:59 a.m.) and revealed the mediport had Methicillin Resistant Staph aureus (MRSA). S2 indicated the mediport had mandated "Contact Precaution" to be implemented by the Registered Nurse/Charge Nurse. The DON indicated there was no documentation of the nurse implementing "Contact Precaution" measures as indicated on the lab result from 5/6/11 through 5/18/11 for about 12 days.

During the same interview held on 5/18/11 at 8:15 a.m., S2DON indicated the Registered Nurse/Charge Nurse is expected to institute the "Contact Precaution" indicated on the patient's laboratory culture reports for Patient #7, #12, #14, and #16 as soon as the culture is collected. S2 reported the Registered Nurse/Charge Nurse is to post a sign reading, "Contact Precaution" on the outside of the patient's door to ensure all staff are aware to follow the precaution measures. The DON stated all staff are to wear personal protective equipment (gloves, gowns and masks) prior to entering the patient's room, remove them (personal protective equipment) in the patient's room after providing direct patient care, and perform handwashing prior to leaving the patient's room for all patients that are on "Contact Precaution" and/or "Respiratory Isolation". The DON stated no personal protective equipment (gloves, gowns, and/or masks) should be worn out of a patient's room that is on "Contact Precaution" and/or "Respiratory Isolation". S2 indicated all personal protective equipment must be removed prior to leaving the patient's room. The DON reported the personal protective equipment is worn to prevent cross contamination of organisms from staff to another patient. S2DON verified there were no policies in the Nursing Policy and Procedure Manuals regarding "Contact Precaution" and/or "Respiratory Isolation" measures to be implemented by all staff providing direct patient care. S2 confirmed there was no policy and procedure for patients on "Contact Precaution" to remain in the room and/or wear personal protective equipment while out of the room. S2DON indicated it is good standards of practice for all patients on "Contact Precaution" to remain in the room at all times and at a minimum to wear personal protective equipment while out of the room to prevent cross contamination in the hospital to other patients.

Review of the Nursing Policy and Procedure Manual revealed there were no policies in the Nursing Policy and Procedure Manuals regarding "Contact Precaution" and/or "Respiratory Isolation" measures to be implemented by all staff providing direct patient care. There were no policy presented during the survey from 5/17/11 through 5/26/11 regarding "Contact Precaution" and/or "Respiratory Isolation".

4)
Patient #2:
Review of the "Nurses Notes" dated 5/16/11 through 5/20/11 revealed there was no documented evidence that the Registered Nurse/Charge Nurse performed a daily assessment of the patient as per policy.

In interview on 5/20/11 at 8:35 a.m., S2DON verified there was no documentation of the daily Registered Nurse/Charge Nurse assessment of the patient from 5/16 to 5/20 every 24 hours as per policy.

Patient #7:
Review of the "Nurses Notes" dated 5/21/11 revealed there was no documented evidence that the Registered Nurse/Charge Nurse performed a daily assessment of the patient every 24 hours as per policy.

In interview on 5/20/11 at 8:35 a.m., S2DON confirmed there was no documentation of the daily Registered Nurse/Charge Nurse assessment of the patient on 5/21 every 24 hours as per policy.

Patient #12:
Review of the "Nurses Notes" dated 5/6/11 through 5/20/11 revealed there was no documented evidence that the Registered Nurse/Charge Nurse performed a daily assessment of the patient as per policy.

In interview on 5/20/11 at 8:40 a.m., S2DON verified there was no documentation of the daily Registered Nurse/Charge Nurse assessment of the patient every 24 hours from 5/6 through 5/20 as per policy.

Patient #14:
Review of the "Nurses Notes" dated 5/15/11, 5/16/11, 5/17/11, 5/18/11, and 5/20/11 revealed there was no documented evidence of the Registered Nurse/Charge Nurse performed a daily assessment of the patient from 5/15 to 5/18 and/or 5/20 as per policy.

In interview on 5/20/11 at 8:40 a.m., S2DON verified there was no documentation of the daily Registered Nurse/Charge Nurse assessment of the patient every 24 hours as per policy.

Patient #16:
Review of the "Nurses Notes" dated 5/6/11 to 5/19/11 revealed there was no documented evidence of the Registered Nurse/Charge Nurse performed a daily assessment of the patient every 24 hours as per policy.

In interview on 5/20/11 at 8:40 a.m., S2DON verified there was no documentation of the daily Registered Nurse/Charge Nurse assessment of the patient every 24 hours from 5/6 to 5/19 as per policy.

The policy titled, "Charge Nurse Responsibilities", with no policy number, Approved date of 7/20/09, Revised date of 2/24/10, with no reviewed date, presented as current "Charge Nurse Responsibilities" on 5/18/11 at 8:30 a.m. was reviewed. The policy indicated the Charge Nurse (RN) is responsible for the overall management of the patient during the assigned shift. The RN is responsible for all patients in the assigned shift, assess every patient daily (in a 24 hour period) and document, and ensure orders are carried out including labs for continuity of care.




26313

Based on record reviews and interviews, the hospital failed to meet the Condition of Participation relative to Pharmacy Services by failing to ensure the implementation of effective systems to ensure the pharmaceutical needs of hospitalized patients were met. This was evidenced by:

1. The hospital's failure to ensure that medications were dispensed in a timely manner by failing to have an effective system in place to ensure that medication orders get to the pharmacy and medications get back to patients promptly so that the medications can be administered as ordered. (cross reference to findings cited at A0501)

2. The hospital's failure to ensure that drug administration errors were identified and immediately reported to the patient's attending physician/practitioner. This failure to identify and report medication errors resulted in the physician/practitioner being unaware that medications were not administered as ordered and resulted in the hospital's inability to ensure that corrective action and/or interventions were implemented to reduce medication errors and/or adverse reactions. (cross reference to findings cited at A0508)

3. The hospital's failure to ensure that all medication orders (except in emergency situations) were reviewed for appropriateness by a pharmacist prior to the first dose is dispensed and/or administered to the patient. (cross reference to findings cited at A0500)

4. The hospital's failure to ensure that a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs. (cross reference to findings cited at A0511)

Based on record reviews and interviews, the hospital failed to ensure all medication orders (except in emergency situations) were reviewed for appropriateness by a pharmacist prior to the first dose being dispensed and/or administered to the patient. Findings:

The hospital's policy/procedure titled "Contacting a Pharmacist" was reviewed. The policy/procedure documents "Nurses should fax all orders over to (name of contracted pharmacy services provider). If they have any concerns regarding the Pharmacy receiving their orders, they are to call them. The LTC store hours are Monday thru Friday 8:00 am to 5:30 p.m., and Saturday 8:00 a.m. to 12:00 p.m. Should the Nurse be faxing orders outside of these store hours, THEY MUST CALL THE STORE AT 337-643-8881 AND LEAVE A MESSAGE ON THE VOICEMAIL TO ALERT THE PHARMACIST THAT THEY ARE FAXING A NEW ORDER TO THE PHARMACY. The Pharmacist on call will return the Nurse's call to confirm their needs".
S28LPN (Licensed Practical Nurse) was interviewed on 5/23/11 at 10:05 a.m. When asked if the nurses are allowed to administer first dose medications from the night supply cabinet outside of normal pharmacy store hours without first verifying review by a pharmacist (Monday thru Friday 8:00 a.m. to 5:30 p.m., and Saturday 8:00 a.m. to 12:00 p.m.), S28LPN indicated the first dose medications can be administered from the night supply cabinet without first verifying review by a pharmacist.
S33 (Liaison for the contracted pharmacy services provider), S34 (contracted pharmacist), and S35 (contracted pharmacist and owner of the contracted pharmacy services provider) were interviewed on 5/25/11 at 9:15 a.m. When asked if the nurses are allowed to administer first dose medications from the night supply cabinet outside of normal store hours (Monday thru Friday 8:00 a.m. to 5:30 p.m., and Saturday 8:00 a.m. to 12:00 p.m.), S33 indicated that nurses are allowed to administer ordered medications from the night supply cabinet outside of normal store hours. When asked if the pharmacist reviews all medication orders, including medications ordered outside of normal store hours when the medication is located in the night supply cabinet, prior to the first dose being administered for the therapeutic appropriateness; therapeutic duplication; appropriateness of the drug, dose, frequency, route and method of administration; real and potential drug-drug interactions, drug-food interactions; real or potential allergies or sensitivities; and other contraindications, S33 indicated the nurses can pull the medications out of the night supply cabinet and administer the first dose prior to the review by a pharmacist. S35 reported the medication orders are reviewed prior to first dose administration "if" the nurses call and inform the pharmacist of the new medication orders first. S33 reported the nurses do not always call first.

Based on record reviews and interviews, the hospital failed to ensure that medications are dispensed in a timely manner by failing to have an effective system in place to ensure the medication orders get to the pharmacy and medications get back to patients promptly so the medications can be administered as ordered. Medication errors were noted in the medical records of 4 of 9 patients (#1, #14, #17, #21), whose medical records were reviewed for administration of medications out of a total sample of 33 patients.
Findings:

Patient #21: Medical record review revealed the patient was admitted to Hospital on 5/19/11 with a diagnosis that included Bacterial Endocarditis. Review of the medical record revealed orders dated 5/19/11 (not timed) for "Penicillin G Potassium 18000000 unit @ 42 ml/hr". Documentation on the order sheet revealed the orders were faxed to pharmacy on 5/19/11 at 5:00 p.m. Review of the medical record including the medication administration record revealed the Penicillin G Potassium 18000000 units @ 42 ml/hr was not administered/started until 5/20/11 at 1:00 p.m. (20 hours after being faxed to pharmacy). There was no documentation in the medical record to indicate the ordering physician was notified of the delay in the initiation of antibiotic therapy for this patient.
S2 Director of Nursing (DON) was interviewed on 5/23/11 at 10:10 a.m. The DON reviewed the medical record of Patient #21 and confirmed the antibiotic was not administered as ordered. The DON reported the antibiotic should have been started on 5/19/11. The DON (S2) also confirmed that there was no documentation to indicate the physician was notified of the delay in the initiation of antibiotic therapy for this patient. When asked if this medication error had been previously identified by staff, S2 DON indicated he had not received a medication administration variance report on Patient #21 and reported he could provide no documentation to indicate the medication error had been previously identified by staff. S2DON reported that many medication errors occur as a direct result of the medications not being available in the hospital for administration.
Patient #17: Medical record review revealed the patient was admitted to Hospital on 5/05/11 with a diagnosis that included Sepsis. Review of the medical record revealed orders dated 5/05/11 at 12:30 p.m. for "Ancef 2 grams IVPB q 8 (hours) X 17 days". Review of the medical record including the medication administration record revealed the patient received only one dose of Ancef on 5/05/11 with the first dose being administered on 5/05/11 at 10:00 p.m. (Review of the hospital's policy/procedure titled "Medication Administration" revealed the scheduled administration times for medications ordered q 8 hours is 6:00 a.m., 2:00 p.m. and 10:00 p.m.) There was no documentation to indicate the 2:00 p.m. dose of Ancef was administered to the patient on 5/05/11. There was no documentation in the medical record to indicate the ordering physician was notified of the delay in the initiation of antibiotic therapy for this patient.
S2DON was interviewed on 5/23/11 at 10:50 a.m. The DON (S2) reviewed the medical record of Patient #17 and confirmed the antibiotic was not administered as ordered. The DON (S2) reported the initial dose of the antibiotic should have been administered at 2:00 p.m. on 5/05/11. He also confirmed there was no documentation to indicate the physician was notified of the delay in the initiation of antibiotic therapy for this patient. When asked if this medication error had been previously identified by staff, the S2DON indicated he has not received a medication administration variance report on Patient #17 and reported that he could provide any documentation to indicate that the medication error had been previously identified by staff. The Director of Nursing (S2) reported that many medication errors occur as a direct result of the medications not being available in the hospital for administration.
Patient #14: Medical record review revealed the patient was admitted to Hospital on 4/21/11 with a diagnosis that included Sepsis. Review of the medical record revealed orders dated 5/21/11 at 5:00 p.m. for "Diflucan 150 mg, 1, po X 1 dose". Review of the medical record including the medication administration record revealed the Diflucan was not administered until 5/23/11 at 11:50 a.m. (42 hours and fifty minutes after being ordered). There was no documentation in the medical record to indicate that the ordering physician was notified of the delay in the initiation of antifungal therapy for this patient. Further review revealed an order dated 4/21/11 at 1:00 p.m. for "Promod 2 tbs, PO, TID". Review of the medical record including the medication administration record revealed the Promod was not administered from 10:00 p.m. on 5/21/11 thru the date and time of this record review on 5/23/11 at 10:35 a.m. resulting in a total of 4 missed doses. Documentation on the progress notes revealed the following:
* Entry dated 5/21/11 at 5:30 p.m. entered by S32 LPN revealed "(name of nurse) RN called pharmacy 3 times to call in medication for (Patient #14) for a new order. Phone rang & rang until phone services were disconnected per pharmacy services answering service did not pick up, will continue to try".
* Entry dated 5/21/11 at 6:15 p.m. entered by S32 LPN revealed "(name of nurse) RN called IV pharmacy and left msg on answering service that she can't get in touch with PO pharmacy concerning (Patient #14's) medication".
* Entry dated 5/22/11 at 2:00 p.m. entered by S32 LPN revealed "Promod not given, not available, called pharmacy multiple times. No answer, answering machine did not pick up".

S32LPN was interviewed on 5/25/11 at 3:45 p.m. S32 reviewed the medical record of Patient #14 and confirmed the medications were not administered as ordered. S32 reported that multiple attempts were made by nursing to contact the contracted pharmacy to inform them of the unavailability of the Diflucan and the Promod. S32LPN reported that the contracted pharmacy was not responding to the phone calls.
The DON was interviewed on 5/23/11 at 10:35 a.m. S2DON reviewed the medical record of Patient #14 and confirmed the antifungal was not administered as ordered. The DON (S2) reported the antifungal should have been started on 5/21/11 after being ordered. S2DON also confirmed there was no documentation to indicate the physician was notified of the delay in the initiation of antifungal therapy for this patient. When asked if this medication error had been previously identified by staff, S2DON indicated he had not received a medication administration variance report on Patient #14 and reported he could not provide any documentation to indicate the medication error had been previously identified by staff. The DON (S2) reported that many medication errors occur as a direct result of the medications not being available in the hospital for administration.
Patient #1: Review of the Medical Record revealed Patient #1 was admitted to Hospital on 03/15/11 with the diagnoses of Debility and a Nonhealing Wound.

Review of the Physician's order dated and time 03/17/11 at 4:00 p.m. revealed an order for Promod 30 cc (cubic centimeters) TID (three times a day). Review of the Medication Administration Record (MAR) for May 19 to May 25, 2011 revealed on 05/22/11 and 05/23/11 three circled areas with "see NN" handwritten to the side of the circle.

An interview was conducted with S37LPN on 05/23/11 at 2 p.m. She stated when the time a medication was due to be administered was circled, it indicated the Promod was not given and "NN" handwritten beside the circle meant to refer to the Nurse's Notes. She went on to state the Promod was not given to the patient over the weekend (total of 3 missed doses) because none was available for the patient and there was none in stock medication. Also she stated she was unable to administer the 2 p.m. dose of Promod today (05/23/11) because it was still not available and the pharmacy didn't bring the facility's medications to 6 p.m.

Review of the Nurse's Notes dated and timed 05/22/11 at 2 p.m. revealed, "no Promod given none in stock called pharmacy multiply times no answer, no answering service picked up." The entry was signed by S32LPN.

An interview was conducted with S32LPN on 05/25/11 at 1:10 p.m. She stated she was the nurse that wrote the nursing note entry on 05/22/11 at 2 p.m. She went on to state the Promod was not available for Patient #1 over the weekend and there was none in the medication cart or in stock medication. She also stated the charge nurse called the pharmacy this weekend and the phone rang and rang and an answering machine did not pick up the call She stated the charge nurse let her hear the phone continuously ringing without being picked up by an answering machine. When questioned if she or any of the other nurses had the personal cell phone number to the pharmacist, she stated no.

S2DON was interviewed on 05/25/11 at 1:20 p.m. He stated he was unaware of the Promod was not available to administer to Patient #1 on 05/22/11 and 05/23/11.

S33 (Liaison for the contracted pharmacy services provider), S34 (contracted pharmacist), and S35 (contracted pharmacist and owner of the contracted services provider) were interviewed on 5/25/11 at 9:15 a.m. S33 and S35 reviewed the orders and medication administration records for Patient's #21 and #14. S33 and S35 confirmed the medications were not administered as ordered and that the documentation indicated that there were delays in the administration of the ordered medications for these patients. S33 and S35 reported that there is a breakdown in the communication between the nurses and pharmacists. S33 and S35 reported that policies/procedures are in place for the nurses to follow in regards to faxing orders to the pharmacy in a timely manner to ensure that the medications are available for administration as ordered. S33 and S35 presented the policy/procedure titled "Contacting a Pharmacist". (Review of this policy/procedure revealed "Nurses should fax all orders over to (name of contracted pharmacy services provider). If they have any concerns regarding the Pharmacy receiving their orders, they are to call them. The LTC store hours are Monday thru Friday 8:00 a.m. to 5:30 p.m., and Saturday 8:00 a.m. to 12:00 p.m. Should the Nurse be faxing orders outside of these store hours, THEY MUST CALL THE STORE AT 337-643-8881 AND LEAVE A MESSAGE ON THE VOICEMAIL TO ALERT THE PHARMACIST THAT THEY ARE FAXING A NEW ORDER TO THE PHARMACY. The Pharmacist on call will return the Nurse's call to confirm their needs".) S33 and S35 reported that the nurses are not calling the pharmacist as indicated in the policy/procedure to ensure the pharmacist is aware of the orders.
In an interview on 5/25/11 at 11:00 a.m., S2DON indicated that many of the delays in obtaining the ordered medications are a result of the contracted pharmacy services provider and not directly related to the nursing staff's failure to call the pharmacist outside of store hours.










26351

Based on record reviews and interviews, the hospital failed to ensure drug administration errors were identified and immediately reported to the patient's attending physician/practitioner. This failure to identify and report medication errors resulted in the physician/practitioner being unaware that medications were not administered as ordered and resulted in the hospital's inability to ensure corrective action and/or interventions were implemented to reduce medication errors and/or adverse reactions.
Findings:

Patient #21: Medical record review revealed the patient was admitted to Hospital on 5/19/11 with a diagnosis, which included Bacterial Endocarditis. Review of the medical record revealed orders dated 5/19/11 (not timed) for "Penicillin G Potassium 18000000 unit @ 42 ml/hr". Documentation on the order sheet revealed the orders were faxed to pharmacy on 5/19/11 at 5:00 p.m. Review of the medical record including the medication administration record revealed the Penicillin G Potassium 18000000 units @ 42 ml/hr was not administered/started until 5/20/11 at 1:00 p.m. (20 hours after being faxed to pharmacy). There was no documentation in the medical record to indicate the ordering physician was notified of the delay in the initiation of antibiotic therapy for this patient. Both pharmacy and nursing failed to identify the delay in the dispensing and/or administration of this antibiotic.
Patient #17: Medical record review revealed the patient was admitted to Hospital on 5/05/11 with a diagnosis, which included Sepsis. Review of the medical record revealed orders dated 5/05/11 at 12:30 p.m. for "Ancef 2 grams IVPB q 8 (hours) X 17 days". Review of the medical record including the medication administration record revealed the patient received only one dose of Ancef on 5/05/11 with the first dose being administered on 5/05/11 at 10:00 p.m. (Review of the hospital's policy/procedure titled "Medication Administration" revealed the scheduled administration times for medications ordered q 8 hours is 6:00 a.m., 2:00 p.m. and 10:00 p.m.) There was no documentation to indicate the 2:00 p.m. dose of Ancef was administered to the patient on 5/05/11. There was no documentation in the medical record to indicate the ordering physician was notified of the delay in the initiation of antibiotic therapy for this patient. Both pharmacy and nursing failed to identify the delay in the dispensing and/or administration of this antibiotic.
Patient #14: Medical record review revealed the patient was admitted to Hospital on 4/21/11 with a diagnosis, which included Sepsis. Review of the medical record revealed orders dated 5/21/11 at 5:00 p.m. for "Diflucan 150 mg, 1, po X 1 dose". Review of the medical record including the medication administration record revealed the Diflucan was not administered until 5/23/11 at 11:50 a.m. (42 hours and fifty minutes after being ordered). There was no documentation in the medical record to indicate the ordering physician was notified of the delay in the initiation of antifungal therapy for this patient. Further review revealed an order dated 4/21/11 at 1:00 p.m. for "ProMod 2 tbs, PO, TID". Review of the medical record including the medication administration record revealed the ProMod was not administered from 10:00 p.m. on 5/21/11 thru the date and time of this record review on 5/23/11 at 10:35 a.m. resulting in a total of 4 missed doses. Pharmacy failed to identify the delay in the dispensing and/or administration of these medications.
The Director of Nursing (S2DON) was interviewed on 5/23/11 at 10:35 a.m. S2DON reviewed the medical records of Patient's #21 & #17. He confirmed the medications were not administered as ordered and there was no documentation to indicate the physician was notified of the medication errors. When asked if this medication error had been previously identified by staff, S2DON indicated he has not received a medication administration variance report on these patients and reported he could provide no documentation to indicate these medication errors had been previously identified by staff. S2DON reported that many medication errors occur as a direct result of the medications not being available in the hospital for administration.
S33 (Liaison for the contracted pharmacy services provider), S34 (contracted pharmacist), and S35 (contracted pharmacist and owner of the contracted services provider) were interviewed on 5/25/11 at 9:15 a.m. S33 and S35 reviewed the orders and medication administration records for Patient's #21 and #14. S33 and S35 confirmed the medications were not administered as ordered and the documentation indicated there were delays in the administration of the ordered medications for these patients. S33 and S35 reported there is a breakdown in the communication between the nurses and pharmacists. S33 and S35 reported policies/procedures are in place for the nurses to follow in regards to faxing orders to the pharmacy in a timely manner to ensure the medications are available for administration as ordered. S33 and S35 presented the policy/procedure titled "Contacting a Pharmacist". Review of this policy/procedure revealed "Nurses should fax all orders over to (name of contracted pharmacy services provider). If they have any concerns regarding the Pharmacy receiving their orders, they are to call them. The LTC store hours are Monday thru Friday 8:00 a.m. to 5:30 p.m., and Saturday 8:00 a.m. to 12:00 p.m. Should the Nurse be faxing orders outside of these store hours, THEY MUST CALL THE STORE AT 337-643-8881 AND LEAVE A MESSAGE ON THE VOICEMAIL TO ALERT THE PHARMACIST THAT THEY ARE FAXING A NEW ORDER TO THE PHARMACY. The Pharmacist on call will return the Nurse's call to confirm their needs". S33 and S35 reported the nurses are not calling the pharmacist as indicated in the policy/procedure to ensure the pharmacist is aware of the orders. S33, S34, and S35 were asked to present all medication variance reports and/or medication error reports for identified medication errors for the most recent 3 months. Review of this documentation revealed no evidence to indicate the contracted pharmacy services provided had identified the medication errors, which occurred for Patient's #21, #17, & #14. When asked about the pharmacist participation in the hospital wide QAPI (Quality Assurance Performance Improvement) program, S33 and S35 reported the pharmacist has little to no involvement in the hospital wide QAPI program at this hospital.
In an interview on 5/25/11 at 11:00 a.m., S2DON indicated that many of the delays in obtaining the ordered medications are a result of the contracted pharmacy services provider and not directly related to the nursing staff's failure to call the pharmacist outside of store hours.

Based on record reviews and interviews, the hospital failed to ensure a formulary system was established by the medical staff to assure quality pharmaceuticals at reasonable costs. Findings:

Review of pharmacy documents revealed no indication of the establishment of a hospital formulary system.

The meeting minutes of the most recent 2 meetings of the Governing Body were reviewed. Documentation in the meeting minutes for the meeting of the Governing Body on 12/21/10 revealed under the Pharmacy and Therapeutics section, "MAR's from the pharmacy continue to be deficient. The DON and Health Information Director will implement a system to sign documents. Formulary needs to be put into place for physicians and PA". Documentation in the meeting minutes for the meeting of the Governing Body on 3/23/11 revealed under the Pharmacy and Therapeutics section, "MAR's from the pharmacy continue to be deficient. The DON and Health Information Director will implement a system to sign documents. Formulary needs to be put into place for physicians and PA".

S33 (Liaison for the contracted pharmacy services provider), S34 (contracted pharmacist), and S35 (contracted pharmacist and owner of the contracted pharmacy services provider) were interviewed on 5/25/11 at 9:15 a.m. When asked if the hospital has a formulary system, S33, S34, & S35 all reported the hospital does not have a formulary system. S35 reported he has discussed with hospital administration on several occasions the need to develop a formulary system but stated that as of the date and time of this interview, the hospital does not have a formulary system. When asked about the process for dispensing medications that are ordered by the physician, S33 & S35 indicated all medications ordered must be approved by either the hospital's Administrator (S1), the hospital's Director of Nursing (S2), or S4 (Infection Control Nurse) prior to the medication being dispensed. S35 reported the hospital will not reimburse the contracted pharmacy for medications unless they are first approved by S1, S2, or S4. When asked if there have ever been any occasions when the ordered medications were not approved by S1, S2, or S4, S35 reported there have not been any occasions when the ordered medications were not approved. When asked if there have ever been any occasions when the ordered medications were delayed pending approval by S1, S2, or S4, S35 reported he is not aware of there being any delays with the approval of the ordered medications.

Based on observation and interview, the hospital failed to ensure all facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality.
Findings:

Observations on 5/25/11 between 10:40 a.m. and 11:30 a.m. revealed the following:

*Sections of rust and flaking paint were noted on the beds in several rooms including, but not limited to, Patient Room #20, Patient Room #22, Patient Room #24, and Patient Room #26.
*Sections of peeling and/or flaking paint were noted on the doors and doorframes throughout the hospital.
*Sections of peeling and/or flaking paint were noted on the ceiling and/or walls throughout the hospital including, but not limited to, the hallways, the shower room, Patient Room #31.
*Sections of cracked and/or broken floor tiles were noted in several areas of the hospital including, but not limited to, the hallway, the shower room, Patient Room #8.
*Sections of baseboard molding were noted to be either missing or separating from the wall in several areas of the hospital including, but not limited to, the hallways, the shower room, Patient Room #22, Patient Room #26, and Patient Room #31.
*Bedside tables in disrepair as sections of cracked and/or broken particle board were noted on the surface area resulting in the inability to ensure a smooth wipable surface for disinfection. Findings noted throughout hospital including, but not limited to, Patient Room #20, Patient Room #22, Patient Room #24, Patient Room #26, and Patient Room #31.
*Patient #10-lid was missing on the toilet tank.
*Patient Shower Room-Whirlpool tub in disrepair as cracks were noted on the seating area of the tub and on the sides of the tub. In addition, the side panel of the tub was noted to be loose and separating from the tub. A buildup of dirt and grime was noted on the floors under the shower mat. A leak was noted from the shower head. Rust was noted on the frame of the drop ceiling.
*Bathroom off main hallway-toilet was inoperable in that it would not flush and was not securely fastened to floor.
*Patient Room #20-Sections of rust and flaking paint was noted on the bedside commode.
*Patient Room #31-toilet not securely fastened to floor.

In an interview on 5/25/11 at 11:30 a.m., the findings were confirmed by S1 Administrator.

Observations made on 05/23/11 at 2:40 p.m. with S16Dietary Manager and S17Maintenance revealed the following:

*Hot Water temperature in patient room # 31 was 131.0 degrees Farenheit.
*Hot Water temperature in patient room # 29 was 131.7 degrees Farenheit.
*Hot Water Temperature in patient room # 9 (different hall/water heater) was 139.0 degrees Farenheit.

On 05/23/11 at 2:45 p.m. S17Maintenance presented his water temperature logs dated May 16, 2011. Review of the logs from all patient rooms and bathrooms revealed all temperatures were documented as being between 110 and 115 degrees Farenheit.

In an interview at the time of the findings, S1Administrator stated the water was too hot and directed S17Maintenance to immediately adjust the water heaters.

Observations made on 05/23/11 at 2:30 p.m. with S16Dietary Manager revealed the following:

*Air Temperature Meadow Hall (rooms 18 - 36) 76.5 degrees Farenheit.
*Air Temperature Pine Hall (rooms) 84.2 degrees Farenheit.
*Air Temperature Administrative Hall 84.5 degrees Farenheit.
*Air Temperature Employee Break Room 88.7 degrees Farenheit.





26458

Based on observations, interviews, and policy reviews, the Infection Control Nurse (ICN) failed to develop and implement policies governing the control of Healthcare Associated Infections (HAIs) as evidenced by having:
1) outdated Infection Control policies and procedures for isolation precautions (CDC guidelines, 1997);
2) outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004); and
3) the information, knowledge and capability to update the manuals but failed to do so. Findings:

1) Outdated Infection Control policies and procedures for isolation precautions (CDC guidelines, 1997):
Observations conducted on 5/17/11 at 12:05 p.m. and 4:40 p.m., revealed six (6) patients' (#1, #3, #4, #5, #6, #11) doors had a sign reading, "Contact Precautions" and one (1) patient's (#2) door had a sign reading, "Respiratory Isolation" out of a total of 17 patients that were on the unit on 5/17/11. During this same observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview was conducted at this time with S3CNA, she confirmed there was one cart available on the unit that was to be used for all 6 patients (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on Respiratory Isolation. In interviews with the staff members (S28LPN, S29LPN, S2DON) conducted on 5/17/11 at 4:20 p.m., they all verified there was one cart available on the unit that was being used for all 6 patients (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on Respiratory Isolation.

Another observation conducted at 12:30 p.m. on 5/17/11 revealed a staff member, (S3CNA) entered Patient #11's room without applying the personal protective equipment as stated in the "Protective Isolation" policy. A second observation at 12:35 p.m. revealed a staff member (S38CNA) walked to Patient #11's room with a wash cloth in her right gloved hand.

Review of the hospital's current Nursing and Infection Control policies provided on 5/23/11 at 11:50 a.m. were reviewed. The following policy titled "General Policies for Isolation, Gowning," Effective Date: 09/01/96; Revisited 11/11/2008 was reviewed; The policy titled, "Methicillin Resistant Staph Aureus (MRSA) Isolation," Effective Date: 09/01/06 was reviewed; Revisited 11/11/2008 was reviewed; The policy titled, "Vancomycin-Resistant Enterococci (VRE) Precautions," Effective Date: 09/01/2008; Revisited 11/11/2008 was reviewed; The policy titled, "General Policies for Isolation: Masks," Effective date 09/01/96; Revisited 11/11/2008 was reviewed; The policy titled, "Body Substance Isolation," Effective date: 09/01/96; Revisited 11/11/2008 was reviewed. Further review revealed there was no current policies regarding "Contact Precaution", "Respiratory Isolation" and/or "Multi-Drug Resistant Organisms" presented during the survey from 5/17/11 through 5/26/11.

2) Outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004):

On 5/18/11 at 8:00 a.m., a housekeeping staff member, (S6) was observed mopping the floor inside Patient #11's room without wearing personal protective equipment and/or gloves as indicated in the the Housekeeping policies for "Isolation Precautions". At 8:10 a.m., S6 Housekeeping was interviewed on 5/18/11. S6 indicated at this time that personal protective equipment must be worn before entering the patient's room. S6Housekeeping stated she did not wear the personal protective equipment as per policy.

The policy titled, "Laundry, Procedure to Pick Up Isolation Linen", with no policy number or revised date(s), Reviewed and Approved date of 6/7/10 was reviewed. The policy indicated the isolation linen must be contained in the RED bag double bag if necessary. The isolation linen can be transported with regular soiled linen, providing isolation linen is clearly marked by being in a Red Bag, they must be closed and undamaged to prevent leakage. Isolation linen will be treated as all linen in the laundry. The use of "Standard Precautions" which is that all linen is treated as potentially infectious.

Review of the policy titled, "Cleaning Procedure: Airborne Disease Patient Room, Daily", policy number 2103, Effective date of 9/12/97, Reviewed and Approved date of 6/7/10, with no revised date, and presented as the hospital's current "Laundry/Housekeeping" policy on 5/19/11 at 4:00 p.m. was reviewed. The policy indicated the proper procedure for cleaning an occupied isolation patient room. The patient rooms are marked by signs warning: STOP-ALERT, supplies and equipment needed, all-purpose cleaner, Germicidal cleaner, clean wet mop, and dust mop. Questions regarding the precautions protective clothing requirements, supplies, equipment, or cleaning procedures should be directed to an environmental service supervisor. Clean all surfaces in the patient room, except the bed, using clean cloths and fresh germicidal detergent. Include the overbed table, bedside stand, sink, countertop, overbed lights, chairs, window ledge and window, thermostats, IV hangers, telephone, doorknobs, and other objects the patient may have touched. Spot wash walls and doors. Using clean cloths and fresh germicidal detergent in the sink, clean bathroom sink, tub, shower, wall fixtures, and towel holder. Discard the cleaning cloths in the red plastic bag and take fresh cloths as needed. Add fresh germicidal detergent to the toilet. Clean the outside of the toilet and the toilet seat and allow to air dry. Use the toilet brush to clean under rim. Add sufficient germicidal cleaner to the toilet to achieve germicidal levels and allow solution to remain in the toilet bowl. Dust mop the floor, using smooth, slow strokes to avoid recontamination of the room. Pick up the dirt with the dustpan. Using a fresh germicidal solution, wet mop the entire floor surface including the corners, and under and around the toilet, sink, bed, and furniture. Handle or dispose of cleaning supplies and equipment as follows:
a) Pour wash water into the toilet and flush immediately,
b) Put cleaning rags and mop heads in the red bag,
c) Place linen in soiled linen bag,
d) Remove full red trash bags and soiled linen bags inside the room to the designated areas, and
e) Wash hands for 15 seconds, using Antimicrobial soap provided at the sink.

Review of the policy titled, "Laundry Operations Manual, Procedure to Sort Soiled Linen", with no policy number or revised date(s), Approved and Reviewed date of 6/7/10, presented as the hospital's current "Laundry/Housekeeping" policy on 5/19/11 at 4:00 p.m. were reviewed. The policy indicated soiled linen will be transported to soiled linen side only. Soiled linen will be sorted in soiled side of the laundry area. Soiled linen will be sorted into groups of white linen (Sheets, Pillow Cases) (Wash Cloths, Bathtowels), (Blankets), heavy soiled (Underpads) Isolation Linen. As linen is sorted from the large transport cart, linen is ready to be launder.

Review of the policy titled, "Cleaning Procedure: Airborne Disease Patient Room, Daily", policy number 2103, Effective date of 9/12/97, Reviewed and Approved on 6/7/10, with no revised date was reviewed. The policy indicated the proper procedure for cleaning an occupied isolation patient room. The patient rooms are marked by signs warning: STOP-ALERT, supplies needed and equipment needed. Questions regarding the precautions protective clothing requirements, supplies, equipment, or cleaning procedures should be directed to an environmental service supervisor. Dust mop the floor. Put cleaning rags and mop heads in the red bag. Put trash bags in red trash bag and double bag. Remove full red trash bags and soiled linen bags inside the room to the designated areas. Wash hands for 15 seconds, using Antimicrobial soap provided at the sink.

Record review of the Housekeeping Policies revealed the in-house laundry had been discontinued as of October 2004, which resulted with a new policy and procedure in place. In an interview with S12 Housekeeping Director, she stated the Policies and Procedures titled "Laundry Operations Manual" became effective on 3/1/04, was reviewed by Medical Director S22MD, and approved by the Governing Body on 6/7/10. She also confirmed no changes were made to the Policies and Procedures since 3/1/07.

3) The information, knowledge and capability to update the manuals but failed to do so:
In an interview conducted on 5/18/11 from 9:30 a.m. through 10:00 a.m., at 11:00 a.m., and at 1:55 p.m., S4LPN, ICN confirmed both the Nursing and Infection Control Policy and Procedure Manuals did not have current policies for "Contact Precaution", "Respiratory Isolation" and/or "Multi-Drug Resistant Organisms" for staff to follow. S4ICN verified the CDC Guidelines used in the Infection Control Manual were dated 1997. S4ICN indicated the hospital's infection control program was using outdated CDC Guidelines since 1997. S4ICN reported the hospital's Infection Control Policy and Procedures were not established, updated annually and revised as necessary since the effective date of 09/01/1996, revisited date of 11/11/2008, Reviewed and Approved date of 6/7/10. S4ICN confirmed the policies titled, "General Policies for Isolation, Gowning, Masks, Miscellaneous Isolation Precautions, Body Substance Isolation, Suggested Approach to Guidelines for Nosocomial Infection Outbreak Investigation" to establish infection control policies and procedures, and review these policies annually, revise the policies as necessary since as per policy since 1996. S4ICN verified the policies titled, "Methicillin Resistant Staph Aureus (MRSA) Isolation, "Vancomycin-Resistant Enterococci (VRE) Precautions, and Protective Isolation", had an Effective Date of 09/01/2006, Revisited Date of 11/11/2008, were not established, updated annually, and revised as necessary as per policy since 2006. S4ICN stated the current Infection Control Manual did not have current policy and procedures for the "Contact Precaution" and Respiratory Isolation" services that the staff are currently providing direct patient care to Patient #7, #12, #14, and #16 on "Contact Precaution" and/or Patient #2 on Respiratory Isolation.

In another interview conducted on 5/19/11 at 2:00 p.m., S4LPN, ICN returned to the room to be interviewed by the surveyors. S4ICN was observed entering the room with a large binder labeled, "APIC". At this time, S4ICN stated I use the information in here as needed when I have questions about something.

During the same interview on 5/19/11 at 1:55 p.m., S4LPN (Licensed Practical Nurse) Infection Control Nurse (ICN) stated the procedure manual had been reviewed and approved by the S22MD, Medical Director on 6/2010. She also confirmed she had not updated the Infection Control Book as per policy. She confirmed the policy related to the care of the client with "Methicillin Resistant Staph Aureus (MRSA)" was outdated since given the information by the State in 1986. S4 indicated she had attended monthly workshops regarding infections and ways to prevent healthcare-associated infections, but did not include this updated information in the hospital's Infection Control Program. The ICN did not have an explanation as to why she did not include the education from the monthly workshops into the Infection Control Program. S4ICN also stated the nursing policy book did not have a policy on MRSA isolation precautions, Contact Precautions, or Respiratory Isolation for the staff to follow with the current patients that were identified in the hospital with this organism.

Record review of S4LPN's, Infection Control Nurse's (ICN's) personnel file revealed that she had attended workshops monthly on infections and ways to prevent healthcare associated infections since 2009 from a nationally recognized organization (CDC).

In another face-to-face interview held on 5/26/11 at 2:30 p.m., S4LPN, ICN confirmed that she had attended workshops on infections and ways to prevent healthcare-associated infections. She also stated after the last survey (2008), the hospital sent her to a workshop to prepare her to take the national certification examination for Infection Control. She added she has not taken the national certification as of today, 5/26/11. S4ICN indicated the hospital's current Infection Control Policy and Procedure Manuals were not updated with the workshop information on infections and ways to prevent healthcare-associated infections.

In a face-to-face interview held on 5/18/11 at 10:00 am, S2DON indicated there was no current policy regarding Patient #7's, #12's, #14's, and #16's "Contact Precaution" and/or Patient #2's Respiratory Isolation for the staff to follow.

In another interview with the Director of Nursing (DON) on 5/23/11 at 11:50 a.m., he provided surveyors policies from the Nursing Service policy book revealed the current nursing policies were not updated since 09/01/1996 for the policy titled "General Policies for Isolation, Gowning," Effective Date: 09/01/96; Revisited 11/11/2008; "General Policies for Isolation: Masks," Effective date 09/01/96; Revisited 11/11/2008; "Body Substance Isolation," Effective date: 09/01/96; Revisited 11/11/2008 and the policies titled, "Methicillin Resistant Staph Aureus (MRSA) Isolation," Effective Date: 09/01/06; Revisited 11/11/2008; "Vancomycin-Resistant Enterococci (VRE) Precautions," Effective Date: 09/01/2006; Revisited 11/11/2008; since 09/01/2006. The DON confirmed the Nursing Service policy manual had not been updated to reflect the current services the hospital was providing at this time, "Contact Precaution" and "Respiratory Isolation". S2DON indicated there was no policy regarding "Multi-Drug Resistant Organisms".

The "Infection Control Policy and Procedure Manual, Performance Improvement Plan, Infection Surveillance/Prevention/Control Process", with no policy or revised date(s), Reviewed and Approved on 6/7/10, presented on 5/19/11 at 4:05 p.m. as the hospital's current "Infection Control Policy and Procedure Manual" was reviewed. The policy indicated the Infection Surveillance/Prevention/Control Nurse is responsible to ensure that infection surveillance, prevention, and control activities are carried out as planned, and for ensuring policy and procedure compliance. He/she has the authority to act on any infection control measure that may place a patient and/or personnel in danger. He/she is responsible to:
1. Assist in providing high level of patient care by reducing the risk of nosocomial infection.
2. Collect infection control data on both patients and staff, review and analyze this data, and
make recommendations for reducing infections.
3. Obtain monthly reports from Environmental Services and Nutritional departments, review
and analyze these reports, and make recommendations for improvement as necessary.
4. Submit a monthly summary of the findings and corrective actions taken.
5. Establish infection control policies and procedures, and review these annually, revising as
necessary.
6. Detect outbreaks (epidemics) of infection as early as possible, and take steps to abort
such outbreaks.
7. Provide input into the scope and content of the employee health program.
8. Provide (as part of new employee orientation) education to all new employees on
infection prevention and control policies and procedures, including the importance of
personal hygiene, utilization of universal precautions, reporting personal illnesses, and
other responsibilities of employees in infection prevention and control.
9. Insure in-service education in all departments and continuum levels and service relative to
infection prevention and control at least annually.

Further review of the hospital ' s current "Nursing" and "Infection Control" Policy and Procedure Manuals revealed there were no current policies regarding " Contact Precaution " , " Respiratory Isolation " and/or "Multi-Drug Resistant Organisms" presented during the survey from 5/17/11 through 5/26/11.




26313

Based on record reviews, observations, and staff interviews, the infection control officer
1) failed to develop a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by:
a) having the rate of Hospital Acquired Infections (HAIs) of 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 of 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 of 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011 as of 5/26/11, and
b) identifying patients with organisms that were not present upon admission and these organisms requiring mandated institution of contact precautions as indicated on the laboratory culture results for Patient #1, #3, #4, #6, #7, #10, #11, #12, #14, #16 for 10 of 10 sampled patients records focused for isolation precaution out of a total of 33 sampled patients;

2) failed to have a system in place for active surveillance of staff practices of asepsis, correct use of PPE, correct use of isolation precautions, proper cleaning of equipment as evidenced by:
a) failing to have documented evidence of monitoring and evaluating handwashing procedures from November of 2010 through 5/26/11,
b) failing to have staff members (S3CNA, S6Housekeeping) wear personal protective equipment (PPE) before entering a patient ' s room and remove the PPE before leaving the patient room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation", and
c) failing to have a policy available for staff to provide isolation precautions as ordered by the attending physician for "Contact Precaution" for 7 of 7 patients on 5/17/11, (#1, #3, #4, #5, #6, #11) and "Respiratory Isolation" for 1 of 1 patient, (#2) out of a total of 17 patients in the facility on 5/17/11 and for 9 of 9 patients on 5/18/11, (#1, #3, #4, #6, #8, #11, #12, #14, #16) and one patient (#2) on "Respiratory Isolation" out of a total of 18 patients in the facility on 5/18/11;

3) failed to have a system in place to ensure the Infection Control Program was updated and revised annually and as necessary by the Infection Control Nurse, (S4ICN) as per policy as evidenced by:
a) having outdated 1997 CDC Guidelines in the current Infection Control binder,
b) having no policy regarding Multi-drug Resistant Organisms (MDRO), Contact Precaution, and/or Respiratory Isolation in the current Infection Control Manual,
c) having incorrect isolation policies (General Policies for Isolation, Gowning and Masks; Miscellaneous Isolation Precautions; Body Substance Isolation) with 1997 CDC Guidelines to be followed for the 12 of 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified on 5/17/11 and 5/18/11 that were on "Contact Precaution" and/or "Respiratory Isolation",
d) having poor infection control practices performed by the staff as evidenced by staff members (S3CNA, S6Housekeeping) not wearing personal protective equipment (PPE) before entering a patients' room and removing the PPE before leaving the patients' room, (S38CNA) with signs posted on the door labeled, "Contact Precaution" or "Respiratory Isolation",
e) having no education of staff and patients regarding the diseases/organisms identified as HAIs in January, February, and March of 2011 as evidenced by having outdated 1997 CDC Guidelines, incorrect Isolation Precaution policies, or established policies for Contact Precaution, Respiratory Isolation or Multi-drug Resistant Organism for the staff providing direct patient care for the 12 patients, (#1, #2, #3, #4, #5, #6, #7, #8, #11, #12, #14, #16) observed and identified during the survey on 5/17/11 and 5/19/11 that were on "Contact Precaution" and/or "Respiratory Isolation",
f) having improper cleaning of patient equipment with "Buckeye Sanicare Lemon Quat" disinfectant cleaner for the bedbound patients by staff not following the special protection (glasses or goggles, rubber gloves or other impervious gloves, maintain adequate ventilation, avoid breathing spray mist, wash thoroughly with soap and water after handling, remove contaminated clothing, and wash clothing before reuse) and special precautions (Do not contaminate water, food or feed by storage or disposal) on the Material Safety Data Sheet, (MSDS) to be implemented and followed while using the cleanser, and
g) having outdated Housekeeping policies and procedures for cleaning rooms and equipment for patients in isolation precautions, (Hospital policies, 2004); and

4) failed to ensure all staff providing direct patient care had Tuberculin (TB) Test results administered and interpreted in 48 to 72 hours as per policy for 7 of 7 personnel files reviewed for TB Test Screening, (S2DON, S3CNA, S8RN, S15LPN, S18CNA, S28LPN, S29LPN) and for 7 of 7 Credentialing Files, (S7PA, S20MD, S21MD, S22MD, S23MD, S24MD, S25MD, S26MD, S27MD).
FINDINGS:

1) Failed to develop a system for identifying, investigating and preventing infectious diseases/organisms in the hospital from being transferred from patient to patient and/or from staff to patient as evidenced by:

a) having the rate of Hospital Acquired Infections (HAI) was 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 was 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 was 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011:
Observations conducted on 5/17/11 at 12:05 p.m. and 4:40 p.m., revealed six (6) patients' (#1, #3, #4, #5, #6, #11) doors had a sign reading, "Contact Precautions" and one (1) patient's (#2) door had a sign reading, "Respiratory Isolation" out of a total of 17 patients that were on the unit on 5/17/11. During this same observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview was conducted at this time with S3CNA, she confirmed there was one cart available on the unit that was to be used for all 6 patients (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on Respiratory Isolation.

Another observation conducted on 5/17/11 at 12:30 p.m. revealed a nursing staff member, (S3CNA) entered Patient #11's room without applying the personal protective equipment as stated in the "Protective Isolation" policy. A second observation conducted at 12:35 p.m. revealed a staff member (S38CNA) walked to Patient #11's room with a wash cloth in her right gloved hand. Further observation conducted on 5/18/11 at 8:00 a.m. revealed a housekeeping staff member, (S6) was mopping the floor inside Patient #11's room without wearing personal protective equipment and/or gloves as indicated in the Housekeeping policies for "Isolation Precautions".

Record review revealed there were 4 patients (#7, #12, #14, #16) whose laboratory findings included Multi-Drug Resistant Organisms (MDRO). According to Center for Disease Control (CDC) Guidelines (2006), contact precautions are mandated for these MDROs. Further observations revealed these 4 patients were not placed on contact precautions from 5/17/11 through 5/18/11.
In interviews with the staff members (S28LPN, S29LPN, S2DON) conducted on 5/17/11 at 4:20 p.m., they all verified there was one cart available on the unit that was being used for all 6 patients, (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on "Respiratory Isolation".

Review of the hospitals' current Nursing and Infection Control policy and procedure manuals revealed there was no current policy regarding "Contact Precaution", "Respiratory Isolation" and/or "Multi-Drug Resistant Organisms" presented during the survey from 5/17/11 through 5/26/11.

Record review of the QA minutes revealed the hospitals ' , Infection Control Nurse identified the rate of Hospital Acquired Infections (HAI) was 12.8 % for the month of January, 2011; the rate of HAIs for the month of February 2011 was 30.6%, which was an increase of 17.8% since the month of January 2011; and the rate of HAIs for the month of March 2011 was 71%, which was an increase of 40.4% since the month of February. The Infection Control Nurse had not calculated the Hospital Acquired Infections for the month of April 2011. Further investigation into the type of organisms, which required contact precautions as mandated by CDC (2006) revealed the following: In January, the MDRO identified included Acinetobacter baumannil complex, Escherichia coli (E. coli), Methicillin resident Staphlococcus aureas (MRSA), a Vancomycin Resistant Enterococcus faecalis (VRE), and Clostridium difficile. In February, the MDRO identified included Staphlococcus epidermis, Clostridium difficile, MRSA, Klebsiella pneumoniae, Strep agalactiae, Group B, Acinetobactor baumannil complex, and Enterococcus faecalis. In March, the MDRO identified included Acinetobacter Baumannil complex, Klebsiella pneumoniae, MRSA, VRE, and Clostridium difficle. In April, the MDRO identified included: Klebsiella pneumoniae, VRE, Acinetobacter baumannil complex, MRSA, Group B Streptococcus, Streptococcus agalactiae Group B, Clostridium difficle, and Escherichia coli.
Review of the "Infection Control" and the Infection Control Nurses' binders revealed there was no documented evidence of the tracking, trending, interventions implemented or corrective actions taken by the ICN (S4LPN) for the hospital acquired infections identified in January, February, and March of 2011. As of today, 5/19/11 at 2:55 p.m., the rate of Hospital Acquired Infections (HAIs) for April was incomplete. There was no documentation of the rates for the April HAIs identified by the Infection Control Nurse, S4 presented during the survey from 5/17/11 through 5/26/11.

In an interview on 5/19/11 at 2:55 p.m., S4LPN, ICN confirmed the rate of HAIs identified in January were 12.8 %; in February was 30.6%, which was an increase of 17.8% since the month of January, and in March was 71%, which was an increase of 40.4% since the month of February. S4ICN verified there was no tracking, trending, or interventions implemented for the hospital acquired infections identified in January, February, and/or March of 2011. S4ICN indicated there was no documented evidence of the corrective actions implemented by the ICN after the rates of HAIs were identified for January of 12.8 %, February of 30.6%, which was an increase of 17.8% since the month of January, and March of 71%, which was an increase of 40.4% since the month of February. During this same interview, S4LPN, ICN stated she allotted about 10 hours a week for Infection Control and Utilization Review.

S22MD, Medical Director was interviewed from 10:25 a.m. through 10:55 a.m., on 5/23/11. He denied what the HAI infection rates for January, February, and March of 2011 were. The surveyor at this time read aloud the documentation of the QA Meeting Minutes with the reported HAIs for January, February, and March of 2011. S22MD confirmed that he had attended the monthly QA Meetings in January, February, and March. The Medical Director verified the rates of HAIs for January was 12.8 %, the rates of HAIs for February was 30.6%, which was an increase of 17.8% since the month of January, and the rates of HAIs for March was 71%, which was an increase of 40.4% since the month of February.

b) identifying patients with organisms that were not present upon admission and these organisms requiring mandated institution of contact precautions as indicated on the laboratory culture results for Patient #1, #3, #4, #6, #7, #10, #11, #12, #14, #16 for 10 of 10 sampled patients records focused for isolation precaution out of a total of 33 sampled patients:
Observations conducted on 5/17/11 at 12:05 p.m. and 4:40 p.m., revealed six (6) patients', (#1, #3, #4, #5, #6, #11) doors had a sign reading, "Contact Precautions" and one (1) patient's (#2) door had a sign reading, "Respiratory Isolation" out of a total of 17 patients that were on the unit on 5/17/11.

During another observation of the unit was conducted on 5/18/11 from 8:05 a.m. through 8:30 a.m. with S5RN, Charge Nurse revealed there were no "Contact Precaution" signs posted on the outside door for Patient #7, #12, #14, or #16 observed during this observation. At this time, S5RN confirmed the patients (#7, #12, #14, #16) did not have a sign reading, "Contact Precaution" posted on the outside of the patient's doors. S5 verified Patient #7's, #12's, #14's and #16's laboratory culture results mandated institution of "Contact Precautions". S5RN reported the patients (#7, #12, #14, #16) should all have a sign posted on the outside of the door indicating "Contact Precaution" must be implemented by all staff providing direct patient care as per policy.

Patient #1:
Review of the patient's medical record revealed the patient was admitted to the hospital on 3/15/11 with a non-healing wound and a history of MRSA right Ischium. Review of the patient ' s right ischium culture collected on 4/5/11 revealed the ischium had Pseudomonas, Klebsiella pneumoniae, Methicillin Resistant Staph aureus (MRSA), and Vancomycin-resistant enterococci (VRE), organisms mandating institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 3/15/11. Review of the right ischium collected on 5/6/11 revealed the ischium had MRSA and Acinetobacter baumannii complex organisms that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 3/15/11.

Patient #3:
Review of the patient's medical record revealed the patient was admitted to the hospital on 12/16/10 with diagnosis of non-healing wound left leg. Review of the patient's urine-supra pubic aspirate culture collected on 3/13/11 revealed the urine had Acinetobacter baumannii complex organisms that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 12/16/10.

Further review of the patient's (#3's) medical record revealed the patient was admitted to the hospital on 12/16/10 with diagnosis of non-healing wound left leg. Review of the patient ' s blood and urine cultures collected on 4/11/11 revealed there was Klebsiella pneumonia organism that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 12/16/10.

Review of Patient #3's blood and urine cultures collected on 5/12/11 revealed there was Klebsiella pneumonia organism in the blood and urine that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 12/16/10.

During a tour of the facility conducted on 5/17/11 at 4:10 p.m., Patient #3's door was observed with a sign reading, "Contact Precaution". Further observation revealed the patient, (#3) was not in the room at this time. At 4:30 p.m., Patient #3 was sitting in his wheelchair watching TV (television) in an area by the nursing station with no personal protective equipment noted at this time.

On 5/17/11 at 4:20 p.m., at 4:30 p.m., at 4:35 p.m., and at 4:40 p.m., S2, Director of Nursing (DON) verified Patient #3 was on "Contact Precaution" as indicated on the signs posted on the patient's door. The DON indicated all patients on "Contact Precaution" should remain in the room at all times as per policy. S2 stated that the patient (#3) was not following policy by being out of the room while on contact precaution. S2DON indicated Patient #3 should be wearing personal protective equipment while out of the room and on contact precaution.

Patient #4:
Review of the patient's medical record revealed the patient was admitted to the hospital on 2/15/11 with diagnosis of non-healing wound, status post left metatarsal amputation. Review of the patient ' s blood culture collected on 3/14/11 revealed there was Clostridium Difficile Colitis (C. diff) organism present mandating institution of contact precautions as required according to the CDC 2006 Guidelines. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 2/15/11.
During the same tour of the facility conducted on 5/17/11 at 4:10 p.m., Patient #4's door was observed with a sign reading, "Contact Precautions". Further observation revealed the patient, (#4) was not in the room at this time. At 4:30 p.m., Patient #4 was observed sitting in his wheelchair wheeling himself down the hallway back to his room and he was not wearing personal protective equipment at this time.

On 5/17/11 at 4:20 p.m., at 4:30 p.m., at 4:35 p.m., and at 4:40 p.m., S2, Director of Nursing (DON) verified Patient #4 was on "Contact Precaution" as indicated on the signs posted on the patient's door. The DON indicated all patients on "Contact Precaution" should remain in the room at all times as per policy. S2 stated that the patient, (#4) was out of the room and not following policy. S2DON indicated Patient #4 should be wearing personal protective equipment while out of the room and on contact precaution.

Patient #6:
Review of the patient's medical record revealed the patient was admitted to the hospital on 1/6/11 with diagnosis of non-healing bilateral hip wound. Review of the patient's blood culture collected on 2/17/11 revealed there was Staph epidermis organism mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 1/6/11.

Further review of the patient's urine cultures collected on 3/13/11 and 5/12/11 revealed the urine had Proteus mirabilis organism with a colony count of 100,000 CFU/ML that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 1/6/11.

Patient #7:
Review of the patient's medical record revealed the patient was admitted to the hospital on 4/1/11 through 4/28/11 with diagnosis of Stage 4 sacral decubitus. Review of the patient ' s sacrum wound culture collected on 5/5/11 revealed the sacrum had Proteus mirabilis organism mandating the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission from 4/1/11 to 4/28/11.

Further review of the patient's medical record revealed the patient was re-admitted to the hospital on 5/4/11 through present 5/26/11 with diagnosis of Stage 4 sacral decubitus. Review of the patient's (#7's) mediport culture collected on 5/9/11 revealed the port had MRSA organism that mandated the institution of contact precautions. Further review revealed there was no documented evidence the patient had these organisms present upon admission on 5/4/11.

On 5/18/11 at 8:15 a.m., the Director of Nursing, (DON, S2) verified Patient #7 did not have a "Contact Precaution" sign posted on the outside of the door. S2DON verified Patient #7's sacrum wound culture collected on 5/5/11 revealed the wound had Proteus mirabalis organism. S2 indicated the lab result indicated "Contact Precaution" measures were mandated. The DON confirmed there was no sign posted on the patient's door indicating "Contact Precaution" measures were being implemented by all staff providing direct patient care. He verified there was no documented evidence of the staff providing the patient direct care implementing "Contact Precaution" measures from 5/5/11 through 5/18/11 for about 13 days. S2 indicated the Registered Nurse/Charge Nurse (S5RN) did not implement the "Contact Precaution" measures to post a sign on the patient's door as per policy. S2DON verified the patient's mediport culture had MRSA identified on 5/9/11. S2 confirmed there was no documentation of "Contact Precaution" measures being implemented by the Registered Nurse as per policy for about 9 days.

Patient #10:
Review of the patient's medical record revealed the patient was admitted to the hospital on 4/30/11 with the Providencia Stuartii organism in the urine.

Further review of the patient's urine culture collected on 5/19/11 at 04:30 (4:30 a.m.) and verified on 5/22/11 at 08:27 (8:27 a.m.) revealed the urine had Providencia Stuartii organism that mandated the institution of contact precautions as required according to the CDC 2006 Guidelines. Further review revealed there was no documentation of Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours.

During another observation of the unit on 5/23/11 at 1:55 p.m., the patient was observed sitting in a wheelchair across from the nursing station with the foley catheter tubing touching the floor about one foot in length. Further observation revealed the patient was not wearing personal protective equipment while out of his room. At this same time, S14RN, Charge Nurse confirmed the patient was out of his room with no personal protective equipment on as per policy. S14RN at this time reviewed the patient's urine culture results on 5/19/11 and indicated the patient was not to be out of his room while on "Contact Precaution" as per policy. S14RN reported the "Contact Precaution" policy indicates all patients must remain in the room at all times. S14RN, Charge Nurse indicated "Contact Precaution" measures were not implemented by the Registered Nurse/Charge Nurse for about 27 hours.

On 5/23/11 at 3:00 p.m., S2DON confirmed there was no sign posted on the patient's door by the Registered Nurse/Charge Nurse as per policy for all patients on "Contact Precaution" mandated by the urine lab resulted this morning (5/23/11) at 8:27 a.m. S2 verified there was no documentation the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/22/10 to 5/23/11 for about 27 hours as per protocol.

Patient #11:
Review of the patient's medical record revealed the patient was admitted to the hospital on 5/9/11 with diagnosis of non-healing wound. Review of the patient's sacrum culture collected on 5/11/11 revealed the sacrum had Klebsiella pneumoniae, Enterococcus faecalis and Pseudomonas aerugeus organisms mandating institution of contact precautions.

During the same observations conducted on 5/17/11 at 12:05 p.m. and 4:40 p.m., there were six (6) patients', (#1, #3, #4, #5, #6, #11) doors observed with a sign reading, "Contact Precautions" and one (1) patient's (#2) door had a sign reading, "Respiratory Isolation" out of a total of 17 patients that were on the unit on 5/17/11. During this same observation, one cart with 2 gowns, 2 masks, and one box of gloves was noted outside of Patient #2's room. An interview was conducted at this time with S3CNA, she confirmed there was one cart available on the unit that was to be used for all 6 patients, (#1, #3, #4, #5, #6, #11) on "Contact Precaution" and the 1 patient (#2) on "Respiratory Isolation".

Another observation conducted on 5/17/11 at 12:30 p.m. revealed a staff member, (S3CNA) entered Patient #11's room without applying the personal protective equipment as stated in the "Protective Isolation" policy. A second observation conducted at 12:35 p.m. revealed a staff member (S38CNA) walked to Patient #11's room with a wash cloth in her right gloved hand. Further observation conducted on 5/18/11 at 8:00 a.m. revealed a housekeeping staff member, (S6) was mopping the floor inside Patient #11's room without wearing personal protective equipment and/or gloves as indicated in the Housekeeping policies for "Isolation Precautions".

In interviews with the staff members, (S28LPN, S29LPN, S2DON) conducted on 5/17/11 at 4:20 p.m., they all verified there was one cart available on the unit that was being used for all 6 patients, (#1, #3, #4, #5, #6, #11) on "Contact Precautions" and the 1 patient (#2) on "Respiratory Isolation".

Patient #12:
Review of the patient's medical record revealed the patient was admitted to the hospital on 3/24/11 to present, 5/26/11 with diagnosis of Decubitus Ischium Stage 4 wound. Review of the patient ' s left ischium culture collected on 5/4/11 revealed the ischium had Proteus mirabilis, Klebsiella pneumoniae, Enterococcus faecalis and MRSA that mandated the institution of contact precautions. Further review of the record revealed there was no documented evidence the patient was admitted with these organisms were present upon admission on 3/24/11.

Further review of #12's medical record revealed there was no documentation that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/4/11 to 5/18/11 for about 14 days.

Further review of the patient's urine clean catch culture collected on 5/6/11 at 04:30 (4:30 a.m.) and verified on 5/9/11 at 08:27 (8:27 a.m.) revealed the urine had Acinetobacter baumannii complex organism mandating the institution of contact precautions. Further review revealed there was no documented evidence the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/6/11 through 5/18/11 for approximately 12 days.

On 5/18/11 at 8:15 a.m., the Director of Nursing, (DON, S2) verified Patient #12 did not have a "Contact Precaution" sign posted on the outside of the door. S2DON reviewed the Patient #12's left Ischium culture collected on 5/4/11 at 09:30 (9:30 a.m.) and verified on 5/8/11 at 08:21 (8:21 a.m.) revealed the Ischium had Proteus mirabilis, Klebsiella pneumoniae, Enterococcus faecalis and Methicillin Resistant Staph aureus (MRSA). The DON indicated the ischium culture result indicated "Contact Precaution" were mandated. S2 verified there was no documentation that the nurse implemented "Contact Precaution" measures as indicated on the lab results from 5/4/11 to 5/18/11 for about 14 days. The DON reviewed the patient's urine clean catch culture collected on 5/6/11 at 04:30 (4:30 a.m.) and verified on 5/9/11 at 08:27 (8:27 a.m.) indicated the urine had Acinetobacter baumannii complex organism. S2 indicated the urine culture mandates the institution of "Contact Precautions" as per policy. S2DON stated there was no documented evidence that the nurse implemented "Contact Precaution" measures as indicated on the urine lab result from 5/6/11 through 5/18/11 for approximately 12 days.

Patient #14:
Review of the patient's medical record revealed the patient was admitted on 4/21/11 with the diagnosis of Stage 4 Sacral Decubitis Ulcer. Review of the patient's sacrum culture collected on 5/15/11 revealed the sacrum had Proteus mirabilis, Klebsiella pneumoniae, and Methicillin Resistant Staph aureus (MRSA) organisms all mandated the institution of contact precautions. Further review revealed there was no documentation the patient had these organisms present upon admission on 4/21/11.

Further review revealed there was no documentation of the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures from 5/15/11 through 5/18/11 for approximately 3 days.

In the same interview on 5/18/11 at 8:15 a.m., S2DON confirmed Patient #14 did not have a "Contact Precaution" sign posted on the outside of the door. S2 verified Patient #14's sacrum culture collected on 5/15/11 at 17:16 (5:16 p.m.), verified on 5/18/11 at 08:11 (8:11 a.m.) revealed it had Proteus mirabilis, Klebsiella pneumoniae, and Methicillin Resistant Staph aureus (MRSA) organisms. S2 indicated the sacrum culture result mandated "Contact Precaution" measures to be implemented. The DON indicated there was no documentation that the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures as indicated on the lab results from 5/15/11 through 5/18/11 for approximately 3 days as per policy.

Patient #16:
Review of the patient's medical record revealed the patient was admitted on 2/25/11 to present, 5/26/11 with the diagnosis of Bilateral Hip Stage 4 Decubitis. Review of the patient ' s left hip culture collected on 4/6/11 revealed the hip had Proteus mirabilis, Escherichia Coli (E. Coli), and MRSA. Further review of #16's record revealed there was no documented evidence the patient had these organisms present upon admission on 2/25/11.

Review of the patient's (#16's) left Hip culture collected on 4/29/11 revealed the Hip had Proteus mirabilis and Escherichia coli organisms both mandated the institution of contact precautions. Further review of Patient #16's record revealed there was no documentation of the patient with these organisms upon admission on 2/25/11.

Review of the Patient #16's mediport culture collected on 5/6/11 revealed the port had MRSA organism mandating the institution of contact precautions. Further review revealed there was no documented evidence the MRSA was present upon the patient's admission on 2/24/11.

Further review revealed of Patient #16's record revealed there was no documented evidence the Registered Nurse/Charge Nurse implemented "Contact Precaution" measures were implemented from 4/29/11 to 5/18/11 for about 19 days.

S2DON was interviewed during the same interview conducted on 5/18/11 at 8:15 a.m. The DON verified Patient #16 did not have a "Contact Precaution" sign posted on the outside of the door. S2 reviewed the patient's left Hip culture collected on 4/29/11 at 07:40 (7:40 a.m.), verified on 5/3/11 at 08:58 (8:58 a.m.) and revealed the Hip had Proteus mirabilis and Escherichia coli organisms. S2 indicated the hip laboratory result indicated mandate institution of "Contact Precaution". The DON indicated there was no documented evidence the nurse implemented "Contact Precaution" measures as indicated on the lab results from 4/29/11 to 5/18/11 for about 19 days as per policy. S2DON reviewed the patient's mediport culture collected on 5/6/11 at 12:20 (12:20 p.m.), verified on 5/8/11 at 07:59 (7:59 a.m.) and revealed the mediport had Methicillin Resistant Staph aureus (MRSA). S2 indicated the mediport had mandated "Contact Precaution" to be implemented by the Registered Nurse/Charge Nurse. The DON indicated there was no documentation of the nurse implementing "Contact Precaution" measures as indicated on the lab result from 5/6/11 through 5/18/11 for about 12 days.

During the same interview held on 5/18/11 at 8:15 a.m., S2DON indicated the Registered Nurse/Charge Nurse is expected to institute the "Contact Precaution" indicated on the patient's laboratory culture reports for Patient #7, #12, #14, and #16 as soon as the culture is collected. S2 reported the Registered Nurse/Charge Nurse is to post a sign reading, "Contact Precaution" on the outside of the patient's door to ensure all staff is aware to follow the precaution measures. The DON stated all staff are to wear personal protective equipment (gloves, gowns and masks) prior to entering the patient's room, remove them (personal protective equipment) in the patient's room after providing direct patient care, and perform handwashing prior to leaving the patient's room for all patients that are on "Contact Precaution" and/or "Respiratory Isolation". The DON stated no personal protective equipment (gloves, gowns, and/or masks) should be worn out of a patient's room that is on "Contact Precaution" and/or "Respiratory Isolation". S2 indicated all personal protective equipment must be removed prior to leaving the patient's room. The DON reported the personal protective equipment is worn to prevent cross contamination of organisms from staff to another patient. S2DON verified there were no policies in the Nursing Policy and Procedure Manuals regarding "Contact Precaution" and/or "Respiratory Isolation" measures to be implemented by all staff providing direct patient care. S2 confirmed there was no policy and procedure for patients on "Contact Precaution" to remain in the room and/or wear personal protective equipment while out of the room. S2DON indicated it is good standards of practice for all patients on "Contact Precaution" to remain in the room at all times and at a minimum to wear personal protective equipment while ou

Based on record reviews and interviews, the hospital failed to ensure that all Rehabilitation Services were ordered by the physician responsible for the care of the patient as evidenced by 5 of 7 focused patient record reviewed for Rehabilitation Services not having physician orders as per the hospital's policy for Rehabilitation Services out of a total sample of 33 patients, (#2, #15, #21, #22, #30).
Findings:

Patient # 2:
Review of the admission orders dated 05/12/11 at 1530 (3:30 p.m.) for Patient # 2 revealed an order for PT/OT Evaluate and Treat.

Review of the Occupational Therapy Evaluation revealed it was performed on 05/13/11 by S31OT. Review of the treatment documentation revealed patient #2 received OT on 05/13/11, 05/15/11, 05/16/11, 05/17/11, 05/18/11, 05/19/11, and 05/23/11.

Review of the Occupational Therapy Evaluation for patient #2 revealed the physician responsible for the care of patient #2 did not sign the Evaluation.

Review of the Physical Therapy Evaluation revealed it was performed on 05/13/11 by S30PT. Review of the treatment documentation revealed patient #2 received OT on 05/13/11, 05/16/11, 05/17/11, 05/18/11, 05/19/11, 05/20/11, and 05/23/11.

Review of the Physical Therapy Evaluation for patient #2 revealed the physician responsible for the care of patient #2 did not sign the Evaluation.

In an interview on 05/24/11 at 1:55 p.m. with S30PT the above findings were confirmed.

In an interview on 05/24/11 at 1:40 p.m. with S22MD, Medical Director, and S7PA both stated that the physician or LIP (licensed independent practitioner) responsible for the care of the patient must order all therapy prior the initiation of therapy.

Patient # 15:
Review of the admission orders dated 05/17/11 at 1345 (1:45 p.m.) for Patient # 15 revealed no order for PT/OT to Evaluate and/or Treat patient #15.

Review of the Occupational Therapy Evaluation revealed it was performed on 05/18/11 by S31OT. Review of the treatment documentation revealed patient #15 received OT on 05/18/11, and 05/19/11.

Review of the Occupational Therapy Evaluation for patient #15 revealed the physician responsible for the care of patient #15 did not sign the Evaluation.

Review of the Physical Therapy Evaluation revealed it was performed on 05/18/11 by S30PT. Review of the treatment documentation revealed patient #15 received PT on 05/1811, 05/19/11, and 05/20/11.

Review of the Physical Therapy Evaluation for patient #15 revealed the physician responsible for the care of patient #15 did not sign the Evaluation.

In an interview on 05/24/11 at 1:55 p.m. with S30PT the above findings were confirmed.

In an interview on 05/24/11 at 1:40 p.m. with S22MD, Medical Director, and S7PA both stated that the physician or LIP (licensed independent practitioner) responsible for the care of the patient must order all therapy prior the initiation of therapy.

Patient # 21:
Review of the orders for Patient # 21 revealed no documented physician's order for PT/OT to evaluate or treat patient #21.

Review of the medical record of patient #21 revealed S31OT performed an Occupational Therapy Evaluation on 05/20/11 and performed therapy on patient on 05/20/11 and 05/23/11. Review of the Occupational Therapy Evaluation for patient #21 revealed the physician responsible for the care of patient #21 did not sign the Evaluation.

Review of the medical record of patient #21 revealed S30PT performed a Physical Therapy Evaluation on 05/20/11 and performed therapy on patient on 05/20/11 and 05/23/11. Review of the Physical Therapy Evaluation for patient #21 revealed the physician responsible for the care of patient #21 did not sign the Evaluation.

In an interview on 05/24/11 at 1:55 p.m. with S30PT the above findings were confirmed.

In an interview on 05/24/11 at 1:40 p.m. with S22MD, Medical Director, and S7PA both stated that the physician or LIP (licensed independent practitioner) responsible for the care of the patient must order all therapy prior the initiation of therapy.

Patient # 22:
Review of the admission orders dated 05/18/11 at 1600 (4:00 p.m.) for Patient # 22 revealed an order for PT/OT Evaluate and Treat.

Review of the Occupational Therapy Evaluation revealed it was performed on 05/19/11 by S31OT. Review of the treatment documentation revealed patient #22 received OT on 05/19/11 and 05/23/11.

Review of the Occupational Therapy Evaluation for patient #22 revealed the physician responsible for the care of patient #22 did not sign the Evaluation.

Review of the Physical Therapy Evaluation revealed it was performed on 05/19/11 by S30PT. Review of the treatment documentation revealed patient #2 received PT on 05/19/11, 05/20/11, and 05/23/11.

Review of the Physical Therapy Evaluation for patient #22 revealed the physician responsible for the care of patient #22 did not sign the Evaluation.

In an interview on 05/24/11 at 1:55 p.m. with S30PT the above findings were confirmed.

In an interview on 05/24/11 at 1:40 p.m. with S22MD, Medical Director, and S7PA both stated that the physician or LIP (licensed independent practitioner) responsible for the care of the patient must order all therapy prior the initiation of therapy.

Patient # 30:
Review of the admission orders for Patient # 30 dated 05/19/11 at 1300 (1:00 p.m.) revealed an order, taken as a verbal order from S22MD by S5RN, for PT (physical therapy)/OT (occupational therapy) Evaluation.

Further review of the medical record revealed the Occupational Therapy Evaluation was performed on 05/19/11 by S31OT. The evaluation included a Treatment Plan which included frequency of treatment and treatment goals. Review of the OT weekly notes revealed patient #30 received therapy on 05/19/11 and 05/23/11.

Further review of the Occupational Therapy Evaluation revealed the physician responsible for the care of patient #30 did not sign the plan formulated by the OT. Review of the physician's order sheet's for patient #30 revealed no order for OT treatment.

In an interview on 05/24/11 at 1:20 p.m. with S31OT she stated she was not aware that the physician must order the Therapy after acknowledging agreement with the physician ordered evaluation of the patient.

Further review of the medical record revealed the Physical Therapy Evaluation was performed on 05/19/11 by S30PT. The evaluation included a Treatment Plan which included frequency of treatment and treatment goals. Review of the PT weekly notes revealed patient #30 received therapy on 05/19/11, 05/20/11 and 05/23/11.

Further review of the Physical Therapy Evaluation revealed the physician responsible for the care of patient #30 did not sign the plan formulated by the PT. Review of the physician's order sheet's for patient #30 revealed no order for PT treatment.

In an interview on 05/24/11 at 1:20 p.m. with S30PT she stated she was not aware that the physician must order the Therapy after acknowledging agreement with the physician ordered evaluation of the patient.

In an interview on 05/24/11 at 1:40 p.m. with S22MD, Medical Director, and S7PA both stated that the physician or LIP (licensed independent practitioner) responsible for the care of the patient must order all therapy prior the initiation of therapy.

Review of a hospital policy titled "Occupational Therapy Department", date issued Sept. 1, 1996, revised 9-1-96, reads in part: "...Procedure: A. Referrals: All individuals in need of Occupational Therapy must be referred by a M.D. All initial orders are to be written by the physician and should state patient's diagnosis, part to be treated, treatments (it's preferred that orders state "evaluation/treatment"), frequency and duration of treatments. Precautions and contraindications should be noted on the initial referral, it is the responsibility of the assigned therapist to obtain this information before assignment begins. Inpatient orders for Occupational Therapy will be written on the inpatient chart under "Physician's Orders"..."

Review of a hospital policy titled "Physical Therapy Service Request for Inpatients", effective September 1,1996, no date reviewed or revised, reads in part: "Physical Therapy orders should contain: 1) Working Diagnosis. 2) Any precautions or contraindications. 3) Treatment Plans. 4) Goals. 5) Frequency and duration of treatment. Any order that does not contain all of the above will be considered an order for an evaluation. The therapist will evaluate the patient and consult with the referring physician to develop an appropriate treatment plan, goals, etc., as needed."

Based on record reviews, and staff interviews, the hospital failed to ensure the data collected was accurate to monitor the effectiveness and safety of service and quality of care as evidenced by failing to have correct data for the Medication Errors identified by the Director of Nursing, (DON, S2) for January, February, and March of 2011 by having 0% medication errors recorded for the January, February, and March of 2011 Nursing Medication Error rates. Findings:

Review of the "QA Meeting Minutes for January, February and March of 2011 revealed there were 0% Nursing and Pharmacy Medication Error Rates reported.

Review of S2DON's handwritten medication errors revealed there were 35 medication errors identified for the month of January, 19 medication errors for the month of February, and 4 medication errors for the month of March of 2011. The DON confirmed the QA Meeting Minutes for January, February, and March of 2011 of the Nursing and Pharmacy Medication Error Rates was 0%. S2DON indicated this is incorrect.

In a face-to-face interview on 5/19/11 at 2:55 p.m., S4ICN verified the rates of HAIs for January was 12.8 %, the rates of HAIs for February was 30.6%, which was an increase of 17.8% since the month of January, and the rates of HAIs for March was 71%, which was an increase of 40.4% since the month of February. S4 verified there was no documented evidence of active surveillance of handwashing performed by the staff from November of 2010 through May 19, 2011. The ICN confirmed there was no documentation of the tracking and trending of the HAIs identified for the months of January, February, and March of 2011 as indicated above. S4 stated there was no documented evidence of any corrective actions taken by S4ICN, S2DON and/or S12Housekeeping Supervisor for the months of January, February, or March of 2011. S4 indicated the same interventions have been implemented every month since November of 2010. The ICN further indicated there are monthly in- services held with all staff on handwashing. S4ICN stated there was no documented evidence that the staff were in compliance with handwashing after the monthly handwashing in-service was held since November of 2010. S4ICN indicated S22MD, Medical Director stated that the HAI rates for January, February, and March of 2011 were not current or accurate infection control rates calculated. S22MD further stated this was inaccurate as well as impossible for the HAI infection control rates to have increased this much for January through March a total of 71%. S22MD stated this calculation was incorrect.
In an interview on 5/19/11 at 3:00 p.m., S2DON and S10RHIM (Registered Health Information Manager) both confirmed there nursing medication error rates reported at the January, February and March of 2011 meetings was 0%. Both S2 and S10 indicated the nursing medication error indicator was inaccurate therefore the monitoring and tracking system was also incorrect.

S22MD, Medical Director was interviewed from 10:25 a.m. through 10:55 a.m., on 5/23/11. He denied what the HAI infection rates for January, February, and March of 2011 were. The surveyor at this time read aloud the documentation of the QA Meeting Minutes with the reported HAIs for January, February, and March of 2011. S22MD confirmed that he had attended the monthly QA Meetings in January, February, and March. The Medical Director verified the rates of HAIs for January was 12.8 %, the rates of HAIs for February was 30.6%, which was an increase of 17.8% since the month of January, and the rates of HAIs for March was 71%, which was an increase of 40.4% since the month of February. S22MD denied knowledge that the Infection Control binder had 1997 CDC Guidelines in it. The Medical Director (S22MD) indicated at this time that laboratory results mandating the institution of contact precautions must be followed by all direct care staff for isolation precautions. S22MD denied knowledge why the contact precaution measures for the patients ' laboratory culture reports was no being implemented by staff as recommended by the CDC Guidelines. S22MD indicated that he expected all staff to follow the contact precautions mandated on the laboratory results immediately.

During the same interview with S22MD, Medical Director on 5/23/11 from 10:25 a.m. to 10:55 a.m., he indicated inaccurate data collected for the January, February, and March of 2011 Nursing and Pharmacy Medication Error Rates reported at the QA Meeting therefore the effectiveness of the quality of care provided to the patients cannot be evaluated, tracked, and trended to identify flaws in the system. Without the accurate medication error rates for Nursing and Pharmacy, no corrective actions can be implemented because there was no reviewing, or analyzing done due to the fact that there were no medication errors reported for January, February, or March of 2011.

Review of the hospital's current "Performance Improvement Plan", Reviewed and Approved date of 6/7/10, presented as current " Performance Improvement Plan " on 5/19/11 at 4:00 p.m., was reviewed. The Plan indicated the indicators must be objective, measurable, based on current knowledge, conform to current standards of acceptable practice. Each department will develop and monitor their own Indicators. The monitoring and evaluation process for data collection is the gathering of information that will be used to determine if indicators and standards have been met. The data analysis will be studied by the committee or team to identify patterns or trends that might indicate problems or opportunities for improvement. The committee will provide specific feedback. Correction action measures will be takened to improve quality of care. The corrective action involves education, supervision, review of procedures, and actions to improve systems. All documentation and communication will be clearly documented for the data and analysis of data communicated clearly and in a timely manner. Communication with the QI Committee with each department will provide a monthly indicator report and narrative analysis to the QI Committee. The representative from each department will serve on the QI Committee. The committee meets monthly to discuss issues (not resolved) within the Hospital, discuss recommendations made, and actions taken and results of actions. The QA Plan is a record of what you will be looking at to monitor the quality of care given by your department. The Trending Sheet is a record of compliance by month. The top triangle under each month is for the number of charts or patients reviewed, the bottom triangle is for percent of compliance. For example, if you reviewed 10 patients and 5 met all the criteria you were monitoring, you would have 50% compliance. By filling in the percent of compliance every month, you will be able to trend results. If you meet your threshold (expected standard of compliance) nothing further is needed. If you do not meet threshold, a Summary Sheet must be filled out (Attachment C) explaining why you did not meet threshold and what you are going to do about it. The Summary Sheet is also used to identify a problem or opportunity to improve care that is not on your QA Plan. Indicators, trending sheets and problems are brought to QA meeting. Department Heads keep original in a binder and copies are given to QA Nurse at meeting. Everyone must attend with all sheets completed for that month. The Quality Assurance Meeting will be held the last Wednesday of each month at noon. The trending sheets is a record of compliance per month.