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Based on observation, interviews, and record review, the Facility failed to ensure one of 33 sampled patients (Patient 27) plan of care was implemented when she was not repositioned every two hours as ordered by her physician. This failure placed Patient 27 at risk for development of pressure ulcers and complications which may arise from such ulcers (e.g. skin breakdown, pressure ulcers, wound formation, and infection).

Findings:

A review of Patient 27's History and Physical (H&P), dated 7/10/17, showed she was a 67 year old admitted 7/10/17 with multiple complex medical problems including extensive heart, lung, and kidney disease, as well as a history of multiple major surgeries and prolonged serious systemic infections. Her attending physician, a medical doctor (MD 1) noted the following in the Physical Exam section of the H&P, "She [Patient 27] is noted with loss of muscle mass and deconditioning. Extreme deconditioning noted in both lower extremities." The report also showed an examination of the "chest" as follows: "She is noted with midsternal incision line extending all the way across the sternum [breastbone] with old crusted blood across the incision line." MD 1 indicated in the report that at the time of examination she noted the presence of "sutures [stitches], ecchymosis [redness] and slight necrosis [non-viable tissue]."

During a concurrent observation and interview on 7/18/17 at 8:44 am, Patient 27 asked a registered nurse (RN 1) to turn her. RN indicated she would right after she completed the medication pass. RN 1 said, "You look anxious. Are you anxious?" Patient 27 said, "I'm anxious." The nurse left the room briefly and determined there was no physician's order for an anti-anxiety medication. RN 1 returned to the bedside and asked, "Is there anything I can do besides medicine to help you be less anxious?" Patient 26 said, "Yes, turn me." In response, RN 1 placed a standard pillow lengthwise under the patient's back and right buttock parallel to but short of reaching the spine.

On 7/18/17 at 9:20 a.m., during an interview, Patient 27 said, "They don't turn me every two hours." And stated she had brought up her concern to staff previously.

A review of Patient 27's Physician's Orders, dated 7/11/17 at 8:00 p.m., and signed by MD 1 showed, "Reposition every two hours. Start 7/11/17 at 20:00."

A review of Patient 27's Plan of Care, dated 7/18/17 at 3:19 p.m., showed she had "impaired skin/tissue integrity." A wound care progress note, dated 7/11/17 at 6:49 p.m., showed, "Patient high risk for skin breakdown d/t [due to] limited mobility. Recommend turning/repositioning every 2 hours ... for pressure injury [pressure sores/ulcers] prevention."

On 7/18/17 at 10:27 a.m., during an interview and concurrent record review, the registered nurse supervisor (RN SUPV 2) indicated the hospital conducted an audit of nursing documentation of repositioning for Patient 27. RN SUPV 2 said, "About sixteen percent of the time we were late." RN SUPV 2 went on to say that the hospital did not have a standard for auditing compliance with repositioning orders but she had allowed a grace period of thirty minutes before or after the two hour mark in her evaluations. RN SUPV 2 indicated there were no policies specifically related to repositioning but the nursing standards the hospital adopted was Lippincott's Nursing Procedures.

A review of the repositioning record documented in the Nurses Notes showed the following instances between 7/11/17 at 8:00 p.m., and 7/18/17 at 9:20 a.m., that Patient 27 was not repositioned every two hours (12 times of 79 opportunities or 15 percent of the sampled time) as follows:

On 7/12/17 at 9:13 p.m., she was repositioned to the left side. She was not repositioned again until 7/13/17 at 12:47 a.m.;

* On 7/13/17 at 7:34 a.m., she was repositioned to the left side. She was not repositioned again until 7/13/17 at 10:28 a.m.;

* On 7/13/17 at 1:02 p.m., she was repositioned to the left side. She was not repositioned again until 7/13/17 at 3:41 p.m.;

* On 7/13/17 at 5:43 p.m., she was repositioned to the right side. She was not repositioned again until 7/13/17 at 7:49 p.m.;

* On 7/14/17 at 11:38 a.m., she was repositioned to the right side. She was not repositioned again until 7/14/17 at 2:42 p.m.;

* On 7/14/17 at 3:47 p.m., she was repositioned to the right side. She was not repositioned again until 7/14/17 at 6:44 p.m.;

* On 7/15/17 at 5:38 a.m., she was repositioned to the right side. She was not repositioned again until 7/15/17 at 8:55 a.m.;

* On 7/15/17 at 11:23 a.m., she was repositioned to the right side. She was not repositioned again until 7/15/17 at 4:23 p.m.;

* On 7/16/17 at 5:37 p.m., she was repositioned to the left side. She was not repositioned again until 7/15/17 at 9:01 p.m.;

* On 7/17/17 at 11:16 a.m., she was repositioned to the left side. She was not repositioned again until 7/17/17 at 2:00 p.m.;

* On 7/17/17 at 2:00 p.m. she was repositioned to her back [supine]. She was not repositioned again until 7/17/17 at 4:51 p.m.;

* On 7/18/17 at 12:46 a.m., she was repositioned to her left side. She was not repositioned again until 7/18/17 at 3:25 a.m.

On 7/18/17 at 4:05 p.m., in an interview with MD 1, she indicated she ordered repositioning for the patient every two hours to prevent open wounds and pressure injuries. MD 1 indicated that her expectation was for nursing staff to alternately reposition her patient onto her left side, prone [back] ,and right side every two hours. She commented about the preliminary findings that repositioning was not documented for the patient. She said, "That is not acceptable." She indicated Patient 27 was not capable to reposition herself independently to her left side and required assistance and encouragement until she got strong enough to do it herself.

On 7/20/17 at 1:40 p.m., in an interview with the Chief Clinical Officer and registered nurse (CCO), he indicated repositioning for Patient 27 was addressed in the wound section of the Plan of Care. The CCO said, "It is my expectation that nursing staff follow the plan of care and the physician's orders." He indicated the purpose of repositioning was to offload [take weight off] the patient's skin. He said, " ...as a method to prevent skin breakdown or deterioration of existing wounds... infection of surgical wounds." He said, "We use Lippincott's as a nursing standard."

A review of the Lippincott's standard defined "pressure ulcers" as a type of wound caused by unrelieved pressure causing damage to the underlying tissue. A review of Skill 9-1 Assisting a Patient with Turning in a Bed, recommends, "Review the medical record and nursing plan of care for patient activity. Identify any movement limitations and the ability of the patient to assist with turning." [Reference: Taylor's Clinical Nursing Skills, 4th Edition, 2015, Wolters Kluwer Health/Lippincott Williams & Wilkins, pp 486-487.

A review of the hospital's policy, titled, Prevention and Treatment of Pressure Ulcers and Non-Pressure Related Wounds, revised 6/2016, showed, "preventative and healthy skin care interventions are utilized and may include but not limited to...Repositioning at intervals determined per patient's risk level and condition." The same policy showed documentation requirements as follows: "Record repositioning regimens, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regimen."


The hospital was asked to provide all nursing documentation available that might explain why the patient was not turned every two hours as ordered. No additional information was provided.

Drugs and biologicals must be prepared and administered in accordance with the orders of the practitioner accepted standards of practice and in accordance with the approved medical staff policies and procedures.

Based on observation interview and record review, the hospital failed to ensure medications were administered to two of 31 sampled patients (Patient 18 and Patient 30) in accordance with the orders of the practitioner and accepted standards of practice when:

1. The hospital failed to ensure a registered nurse (RN 1) flushed a patient's (Patient 18) gastrostomy tube (also known as a g-tube)with purified water instead of a laxative solution during administration of medications. The hospital's failure placed the patient at risk for treatment failure secondary to decreased absorption of co-administered medications and placed her at risk for a preventable surgical procedure to replace the g-tube had it become irreparably clogged as a result of failure to flush with purified water in accordance with accepted nursing standards published by Lippincott's Nursing Procedures.

2. The hospital failed to ensure a registerd nurse (RN 4) initiated a continuous infusion insulin (a hormone used to maintain blood glucose levels within a predetermined range determined by the prescriber) to Patient 30 at the right rate and at the right time which placed the patient at risk for adverse outcomes related to preventable medication errors with insulin (e.g. diabetic coma).

Definitions:

Gastrostomy is a surgical procedure for inserting a tube through the abdomen wall and into the stomach. The tube is used for feeding, drainage or medication administration. [Reference: medical-dictionary.thefreedictionary.com]

Diabetic coma develops in severe and inadequately treated cases of diabetes mellitus and is commonly fatal, unless appropriate therapy is instituted promptly [Reference: medical-dictionary.thefreedictionary.com]

High-Alert Medications - Medications that bear a heightened risk of causing significant patient harm when they are used in error. Examples of high-alert medications include insulin..." [Reference ISMP.org]


Findings:

1. A review of Patient 18's History and Physical (H&P), dated 6/24/17, showed she was an 86 year old admitted 6/15/17 with multiple medical problems including diabetes, stroke, hypertension [high blood pressure], respiratory failure, and sepsis. Sepsis is a complication caused by the body's overwhelming and life-threatening response to an infection, which can lead to tissue damage, organ failure, and death. [Reference: cdc.gov] The H&P indicated Patient 18 had a PEG tube. A Percutaneous Endoscopic Gastrostomy is a type of g-tube tube. [Reference: medical-dictionary.thefreedictionary.com/PEG] Patient 18's record showed she had dysphagia (difficulty swallowing) [Reference: nidcd.nih.gov]

On 7/18/17 at 9:48 a.m., during a medication pass observation and concurrent interview with a registered nurse (RN 2), she prepared medications to administer via Patient 18's g-tube. The nurse diluted Mirilax (generic name polyethylene glycol) powder 17 grams (a laxative medication) with a cup of tap water from the patient's bathroom faucet in a plastic quart container and stirred until it was completely dissolved. She crushed a tablet of pantoprazole 40 milligrams (mg) (an acid-reducing medication) with a pill crusher and placed in a one ounce plastic medicine cup. She crushed a tablet of furosemide 20 mg diuretic medication with a pill crusher and placed in a one ounce plastic medicine cup. She crushed a tablet of aspirin 81 mg (a medication used to make blood cells less sticky) with a pill crusher and placed in a one ounce plastic medicine cup. She crushed a tablet of metoprolol 25 mg (a blood pressure-lowering medication) with a pill crusher and placed in a one ounce plastic medicine cup. She partially filled a quart plastic container with tap water and diluted each tablets individually with 30 milliliters (mL) of tap water and stirred with the syringe tip until each was dissolved. She placed all the containers on the patient's bedside table. Using a 60 milliliter graduated syringe barrel she flushed Patient 18's g-tube with 30 milliliters of tap water then completely administered the furosemide suspension using gravity. She flushed the g-tube with 30 mL of Mirilax suspension. She completely administered the aspirin suspension then flushed the g-tube with 30 milliliters of Mirilax suspension. She completely administered the pantoprazole solution then flushed the g-tube with 30 mL of Mirilax suspension. She paused and said, "I think I flushed with Mirilax not water. They look similar." She flushed the g-tube with 30 mL of tap water then administered the metoprolol solution. She performed a final flush of the g-tube with tap water. RN 1 indicated she customarily used tap water to flush g-tubes. She said, "We don't have distilled water."

On 7/20/17 at 1:40 p.m. during an interview, the Chief Clinical Officer and registered nurse (CCO) indicated nurses were routinely evaluated during medication pass observations using a medication administration audit tool to ensure they were preparing and administering medications correctly. He said, "The nurses use tap water when administering medications through a g-tube." In the same interview he said the hospital used Lippincott as a source of current nursing standards.

A review of the hospital's procedure, titled, Medication Administration - Audit Tool, revised 6/2017, did not address the type of water needed to flush a gastrostomy tube during medication administration.

Excerpts from the hospital's procedures titled, "Lippincott's Nursing Procedures - Gastrostomy tube drug instillation", dated 5/26/17, provided by the CCO included:

* Under the equipment section, the procedure instructed staff to use "purified water" defined as, "sterile, distilled, ultra-filtered, or ultraviolet-light treated"
* Under the implementation section, the procedure described "crushing simple compressed tablets to a fine powder using a mortar and pestle or a pill-crushing device and mix with purified water..."
* Don't mix together different medications intended for administration through the gastrostomy tube because of the risk of physical and chemical incompatibilities, tube obstruction, and altered therapeutic response."
*Flush the gastrostomy tube again with at least 15 mL of purified water, taking into consideration the patient's fluid volume status."
*Repeat the procedure with the next medication..."
*If the patient's gastrostomy tube becomes clogged, flush the tube with water. If flushing with water is unsuccessful, notify the practitioner; a pancreatic enzyme solution, an enzymatic declogging kit, or a mechanical declogging device may be considered before exchanging the tube for a new one."

A review of the hospital's policy, titled, Administration of Enteral Nutrition, revised 6/2017, showed, "Fresh tap water is used to flush tubing and provide extra water as needed to the patient." [The hospital] obtains water from reliable, reputable sources (usually municipal water source) that monitor water quality." The policy did not address the type of water needed to flush a gastrostomy tube during medication administration.

2. A review of Patient 30's medical record showed she was a 92 year old admitted 4/7/17 with a diagnosis of diabetes. A review of her electronic Physician's Orders, dated 4/12/17 and untimed, signed by a medical physician (MD 2) showed an order for insulin infusion 250 units in 250 mL Sodium Chloride 0.9%, concentration 1 unit per mL on 4/12/17 at 10:01 a.m.. The order indicated the insulin infusion was "time critical medication - follow policy", a high alert drug, and the glucose target range was 140-180 mg/dL (milliliters per deciliter). Insulin is a hormone used to manage hyperglycemia, a condition of high blood glucose levels. An additional Physician's Order, dated 4/12/2017 at 10:46 a.m., tilted IV [Intravenous] Insulin Infusion Order, showed the physician ordered "Algorithm 1" for initiation of the infusion, which specified 6 units of insulin should be the starting rate for a blood glucose measurement of 360 mg/dL or over. A review of the laboratory record showed a finger stick blood glucose of 457 mg/dL was obtained at 11:23 a.m..

A review of the Medication Administration Record (MAR) showed that the insulin infusion was started by RN 4 on 4/12/17 at 12:32 p.m. at the rate of 5 units per hour. RN 4 was not available for interview during the survey after the finding.

On 7/19/17 at 11:00 a.m., during an interview with Patient 30's attending physician (MD 2) he said, "I gave an order for [sliding scale] insulin coverage - we could not run the drip [insulin infusion] right away." He said, "I was notified it was late. It warranted a medication error report." MD 2 indicated the sliding scale insulin was a workaround because of late administration of the insulin infusion. He indicated he recalled they were moving beds around in the Intensive Care Unit and for that reason it was impossible to start.

On 7/19/17 at 11:20 a.m., during an interview with the Pharmacist-in-Charge (PIC), he indicated he was unaware of any quality process to ensure nurses adhered to the insulin protocol or ensure it was reported when the protocol was not implemented as ordered. He said he intended to file a medication error report because the insulin infusion was initiated at the wrong rate [wrong dose] of five units per hour rather than six units per hour, as specified in the order, in accordance with Algorithm 1, because the patient's blood glucose of 457 mg/dL obtained on 4/12/17 at 11:23 a.m. before the start of the infusion was greater than 360 mg/dL. In the same interview, the PIC indicated that although the insulin infusion didn't start until 12:32 p.m. (1 hour and 14 minutes after the order was faxed to the pharmacy) he did not consider it a medication error. The PIC said, "Insulin infusion is not really a time critical med here."

A review of the hospital's policy, titled, Timely Administration of Scheduled Medications, revised 6/2017, showed, "Time-critical scheduled medications shall be administered 30 minutes before or after the scheduled dose time. Time critical medications lists will include a limited number of drugs where delayed or early administration of more than 30 minutes may cause harm or subtherapeutic effect." The policy specified that "Medications requiring therapeutic blood monitoring" "are considered time-critical scheduled medications."

A review of the hospital's procedure, titled, Medication Administration - Audit Tool, revised 6/2017, showed, the audit was specifically looking for "correct dosage" and "correct time of administration".

On 7/20/17 at 1:40 p.m., during an interview, the COO indicated nurses were routinely evaluated during medication pass observations using a medication administration audit tool to ensure they were preparing and administering medications correctly. In the same interview, the PIC indicated the hospital had determined this insulin administration fit the criteria for a medication error which was reported due to the finding on the survey. He said, "The infusion started late and at the wrong rate. There was no bolus [one time dose].

Based on observation interview and record review, the facility did not maintain accurate records on 1 of 31 sampled patients (Patient 3) when only one of two episodes of patient 3 being found out of bed was recorded in his chart. This failure made accurate outcome evaluation of interventions difficult.

In an observation on 7/18/17 at 11:25 a.m., Patient 3 was seen on the left side of the bed sitting on the floor. His right arm was stretched across the bed. His wrist was tied to the Left side of the bed with a soft restraint. He was calling out in a muffled voice. Patient 3 was eventually helped back on the bed and asked not to get out again. Patient 3's physician was notified and she ordered increased sedative medications.

In an observation on 7/18/17 at 1505 Patient 3 was sitting on the floor on the left side of the bed with his right arm stretched across the bed tied by the wrist to the left side of the bed having similar to the previous episode. This time a rapid response was called several staff entered the room and helped Patient 3 back into his bed. Patient's physician was notified who came down to see the patient.

A review of the Nursing Notes and Care Plan from the previous day (7/18/17) showed that patient 3 was out of bed once around 1130 a.m. The second episode was not recorded.

An observation of Patient 3 on 7/19/17 at 10:40 a.m. revealed that Patient 3 was sitting up in bed and was surrounded by netting on all sides of the bed.

In an interview on 7/19/17 at 1100 Charge Nurse 1 (CRN 1) stated that Patient 3 was placed in a Poesy bed (a bed that looks like a crib but made for an adult patient) sometime last night. CRN 1 went on to say that any change in condition was supposed to be documented in the nursing notes and being found out of bed when one was restrained was such an event. CRN 1 confirmed that only one episode of Patients 3 getting out of bed was recorded in his medical record and that there was no documentation about when Patient 3's bed was changed to the Posey bed. CRN 1 stressed the importance of accuracy of the medical record and stated that any changes, interventions, and responses should be accurately documented.

A review of the facility Policy "General Documentation Guidelines", last revised on 6/2017, revealed that it is "The policy of the Kindred Hospital is to ensure the Following ... to facilitate consistency and continuity in patient care the medical record contains very specific date and information including ... clinical observations; patient's response to care; ..."

Based on observation, interview and record review, the facility failed to ensure a physician signed the order for use of an additional limb restraint in one of 31 sampled patients (Patient 10). This failure had the potential to result in unnecessary application of a physical restraint, without physician oversight or review, and could result in physical or emotional harm.

Findings:

A review of Patient 10's History and Physical dated 6/17/17 reflected an admission for treatment of conditions which included: brain injury from ruptured blood vessels in the brain; tracheostomy care for respiratory failure (A tracheostomy is a surgical hole in the neck into the trachea [windpipe] to facilitate breathing); gastrostomy tube care (A gastrostomy tube is a surgical hole through the abdomen into the stomach to provide nutrition directly to the stomach for people who have difficulty eating/swallowing.); and care of a centrally placed intravenous line (A central IV is created when a flexible tube is inserted into a large blood vessel of the head, arm, neck, or leg, and then the tube is advanced into the vessel until it reaches a larger vessel near the heart. A central IV delivers medications and fluids more reliably, and for longer time periods, than an IV placed in a non-central site.)

During an observation 7/18/17 at 11:35 a.m., Patient 10 laid on his back with his right hand covered by a mitten, and a soft restraint, secured to the bed frame, wrapped around his right wrist.
During an interview and concurrent review 7/18/17 at 11:47 a.m., Health Information Manager (HIM) confirmed the facility Restraint Initiation/Order dated 7/13/17 had no physician signature in the Physician Assessment/Restraint Order Confirmation section. HIM said the previous order, dated 7/11/17 had only indicated use of a right hand mitten for restraint; the 7/13/17 order had added use of a right hand limb restraint.

The facility Restraint Initiation/Order dated 7/13/17 indicated the Physician Assessment/Restraint Order Confirmation was, "to be completed within 1 (one) calendar day from initiation of the restraint." The form also reflected in the area above the physician signature line, "I have completed a comprehensive assessment of this patient including potential medical problems that may be contributing to the patient's present behavior. I have determined that the restraint(s) are medically necessary for a limited period of time ..."

The facility, "General Documentation Guidelines," released 6/2017 reflected, "All clinical entries in the patient's medical record shall be accurately dated, timed, and authenticated and their authors identified."

Based on observation, interview and record review, the hospital failed provide pharmaceutical services to meet the needs of their patients related to ensuring timely dispensing of high-alert time-critical medication, medication storage, staff supervision for re-packaging activities, provision of medication-related information to care professionals within the hospital based on current standards, and coordinating amd directing the provision of medication-related care during pharmacy staff shortages. The hospital's failure placed all patients at risk for adverse outcomes related to preventable medication errors (e.g. wrong drug selection, repackaging errors, treatment delay and wrong dose with insulin that could result in coma, infection resulting from direct contamination and a potential for preventable surgical procedures, and dispensing errors related to inadequate pharmacist staffing.) The hospital census was 33.

Definitions:

High-Alert Medications - Medications that bear a heightened risk of causing significant patient harm when they are used in error. Examples of high-alert medications include insulin..." [Reference ISMP.org]

The American Society of Health-System Pharmacists (ASHP) is a nationally recognized standards bearer for the pharmacy profession.

Findings:

1. According to the American Society of Health-System Pharmacists, "The pharmacy shall have responsibility for developing policies, procedures, and quality assurance programs regarding drug delivery systems, administration devices, and automated distribution devices that ensure safety, accuracy, security, and patient confidentiality. The potential for medication errors associated with such systems and devices should be thoroughly evaluated." (Reference: ASHP technical assistance bulletin on hospital drug distribution and control. 2010; 67:483-90).

A review of Patient 30's medical record showed she was a 92 year old admitted 4/7/17 with a diagnosis of diabetes. A review of her electronic Physician's Orders, dated 4/12/17 and untimed, showed an order for insulin infusion 250 units in 250 mL [milliliters] Sodium Chloride 0.9%, concentration 1 unit per milliliter on 4/12/17 at 10:01 a.m. The order indicated the insulin infusion was "time critical medication - follow policy."

Regulation of glucose metabolism is the primary activity of insulin. Intravenous administration of Humulin R U-100 [insulin] is possible under medical supervision with close monitoring of blood glucose and potassium levels to avoid hypoglycemia and hypokalemia. [Reference: Dailymed.] Hyperglycemia means high blood sugar or glucose [Reference: medlineplus.gov] Untreated hyperglycemia can lead to diabetic coma.

A review of the hospital's policy, titled, Timely Administration of Scheduled Medications, revised 6/2017, showed, "Time-critical scheduled medications shall be administered 30 minutes before or after the scheduled dose time. Time critical medications lists will include a limited number of drugs where delayed or early administration of more than 30 minutes may cause harm or subtherapeutic effect." The policy specified that "Medications requiring therapeutic blood monitoring are considered time-critical scheduled medications."

A review of the faxed companion order titled, IV Insulin Infusion Orders, dated 4/12/17 at 10:46 a.m., showed the pharmacy received the order. A review of the dispensing record showed a staff pharmacist (RPh 4) verified the medication on 4/12/12 at 11:20 a.m..

A review of the Medication Administration Record (MAR) showed that the insulin infusion was started by a registered nurse (RN 4) on 4/12/17 at 12:32 p.m. at the rate of 5 units per hour. RN 4 was not available for interview during the survey after the finding.

On 7/19/17 at 11:00 a.m., during an interview with Patient 30's attending physician (MD 2) he said, "I was notified it was late. It warranted a medication error report." He indicated the sliding scale insulin was a workaround because of late administration of the insulin infusion.

On 7/19/17 at 11:20 a.m., during an interview the Pharmacist-in-Charge (PIC) said, "Insulin infusion is not really a time critical med here." He indicated the hospital had not this as a medication error to the hospital's quality assurance committee. He said, "The pharmacist checks the drip rates to make sure the nurse is following the protocol." He indicated that non-adherence to the protocol was not reported by the nurse or pharmacist repsonsible for this patient's insulin therapy.

On 7/20/17 at 1:40 p.m., during an interview, the COO indicated nurses were routinely evaluated during medication pass observations using a medication administration audit tool to ensure they were preparing and administering medications correctly. A review of the hospital's procedure, titled, Medication Administration - Audit Tool, revised 6/2017, showed, the audit was specifically looking for "correct dosage" and "correct time of administration".

On 7/20/17 at 1:40 p.m., during an interview, the PIC indicated the hospital had reconsided and determined Patient 30's insulin administration fit the criteria for a medication error which warranted reporting. He said, "The infusion started late and at the wrong rate. There was no bolus [one time dose]. The PIC said, "I reported the med error."

2. On 7/18/17 at 11:41 a.m., during an inspection of the pharmacy, a one pound carton of Magnesium Sulfate U.S.P, [United States Pharmacopeia], a soaking agent used to relieve sore muscles, NDC number 24385-807-01, was observed on a shelf in the pharmacy. The carton had a red auxiliary label affixes which showed, "For External use ONLY." Directly beneath the carton, a barcoded label affixed to the shelf showed, "Gas Relief Drop Infant 30." On the same shelf, there were two bottles of Chloraseptic (a topical throat spray for internal use) NDC number 78112-0110-48, and two bottles of Lidocaine Oral Topical Solution (Viscous 2%), 100 milliliters (mL), NDC number 503830-775-04. The Chloraseptic and Lidocaine bottles had corresponding barcoded labels affixed to the shelf beneath the products.

On 7/18/17 at 11:41 a.m., during an interview with a pharmacist (RPh 1), she said, "It's in the wrong place."

On 7/18/17 at 3:45 p.m., during an interview, the Pharmacist-in-Charge (PIC) said, "I expect medications intended for internal use to be stored separately ...not on the same shelf ...as meds [medications] intended for external use. Epsom salts [brand name for magnesium sulfate] is a soak. We don't use it for a laxative. It's in the wrong place."

3. On 7/18/17 at 11:41 a.m., during an interview, staff pharmacists (RPh 1 and RPH 2) indicated they routinely supervised technicians responsible for repackaging medications for individual patients from stock bottles. RPh 2 said, "When I was trained here I was told what we do here. I don't have a record." She indicated the re-packaging training lasted 30 minutes and she received it November 2016. In the same interview, RPh 1 said, "I trained on repackaging December 2016."

On 7/18/17 at 1:35 p.m., during an interview, the PIC said, "I do not have repackaging records for [RPh 1 and RPh 2] ...not in the employee file." The PIC indicated he had not assessed competencies for repackaging for the professional staff since he took charge of pharmaceutical services.

4. On 7/18/17 at 1:35 p.m., during an interview, the PIC described how he provided information on medication-related information to care professionals within the hospital. He said he had not yet been to a Pharmacy and Therapeutics because it had been cancelled due to the State survey. He said, "I didn't assess the pharmacist's competencies when I took the job. I have not had a chance to do that since ...Board of Pharmacy ...The Joint Commission ...short staff ...bereavement ...jury duty. I've [only been the] PIC since June 6th, 2017." He indicated he had a quality report dated 4/13/17 for the compounding contractor but had not had a chance to review them. He said, "I asked for it after the survey started."

5. On 7/17/17 at 1:20 p.m., during an interview, the PIC discussed and provided two reports required by July 1, 2017 by California State Board of Pharmacy. The first was titled, Compounding Self-Assessment, which was signed by the PIC on 6/14/17 and signed by the COO and dated 6/23/17. The second was titled, Hospital Pharmacy Self-Assessment, which was signed by the PIC on 6/14/17 and signed by the COO and dated 6/23/17. The PIC indicated he submitted the reports to the COO, an administrator, as directed by his supervisor, Senior Pharmacy Director (Sr Pharm Dir).. The PIC indicated he did not have any assistance filling out the reports. He indicated he was not familiar with the definition of some of the terms in the report (e.g. "dangerous drugs" and "centralized hospital packaging pharmacy"). He said, "The reports were probably inaccurate." He indicated he would review them with his supervisor. He was asked to explain his rationale for marking items on the self-assessment as "not applicable." He appeared unsure of several answers he had marked on both reports. In a follow up interview, the PIC indicated he would probably "change to yes" several of his previous responses. A review of the reports showed no obvious inaccuracies.

6. On 7/17/17 at 3:15 p.m., during an interview, the Pharmacist-in-Charge (PIC) described his responsibilities for staffing and coordinating the activities of the pharmaceutical service. He indicated he was hired by a contracted pharmaceutical services provider three weeks prior to the survey. He indicated he was responsible for a staff of three full time pharmacists, four per-diem pharmacists and nine technicians. He indicated his immediate supervisor was a pharmacist in Arizona. The PIC indicated that his 12-week orientation to the position had been delayed. He said, "Since I got here we've had the Board of Pharmacy ...The Joint Commission ...now you." He said since he'd arrived there had been "staff shortages in the pharmacy ...due to ... jury duty...maternity leave...and bereavement leave." He indicated he had no previous supervisor or management experience.

On 7/19/17 at 4:15 p.m., during an interview, the Chief Executive Officer (CEO) indicated the hospital contracts the PIC's professional pharmaceuticals services through a provider. She said, "I'm his [the PIC's] supervisor in the hospital and [Sr Phar Dir] is his supervisor too." She indicated she was unaware that the PIC had asked for staffing help. She said, "He never asked me." The CEO said, "She [Sr Phar Dir] needs to be here in the hospital to proctor him...a proper orientation and education in the role." She indicated how glad the hospital was to have the PIC aboard and said, "I want to support him."

On 7/20/17 at 9:30 a.m., during an interview, the Sr Pharm Dir indicated the PIC was assigned responsibility for supervision and coordination of all activities of the pharmaceutical services. She said he was "on week two of a twelve week onboarding process" intended to ensure competency was established to provide oversight of the hospital's pharmaceutical services. She indicated she and hospital administration knew the PIC had no prior supervisory work experience or management experience. She explained that was not a job requirement. She said, "Everyone has to start somewhere." When asked if the PIC ever asked her for staffing help she said, "No, but I could ask." She indicated that the PIC needed time to learn the pharmacy order entry system and staff pharmacist training.

A review of the hospital's undated Pharmacy Staffing Plan provided by the CEO showed, a "target of 0.9 hours per patient day" for pharmacists, based on patient census, had not been met for June and July of 2017. The plan showed staffing deficiencies in June and July inculded pharmacy technician "call outs", technicician and pharmacists bereavenments leave, jury duty, and maternity leave.

Based on observation and interview the hospital failed to maintain safe and proper storage in a manner that prevents cross-contamination when Nephro therapeutic nutrition was stored inappropriately.
This failure had the potential to induce adverse conditions and compromise patients' health.


Findings:

In an observation of the third floor utility supply room and concurrent interview on 7/17/17 at 9:30 a.m., with the Director of Nursing (DON) there were two dozen cans of Nephro therapeutic nutrition supplements stored inside the bottom cabinet. The protective plastic covering was not intact. There was an ice machine located on top of the cabinet connected to a drain pipe that drained overflow water to a pipe inside the bottom cabinet. The inside walls of the bottom cabinet was warped (distorted) and had a large area covered with black materials not unlike mold. This finding was confirmed by the DON. The DON stated the nephro supplements should not be stored in the bottom cabinet because of the "unsanitary condition and water damage that could be a potential source for contamination."

In an interview on 7/18/17 at 10:40a.m., the Materials Clerk (MC) stated the materials department delivers the Nephro to the unit and stores them on the storage rack or inside a clean cabinet. The MC opened the bottom cabinet and added the cabinet was not a safe storage place for the supplements because "it's very unsanitary and it does not look clean."

In an interview on 7/18/17 at 10:58 a.m., the Materials Management Manager (MMM), stated that the staff from materials management would not store any of the supplies inside the dirty bottom cabinet. The MMM added, "it does not look clean, it looks water damaged" and there were black materials inside.

In an interview on 7/18/17 at 11:10a.m., the Chief Engineer (CE) stated that he had been employed at the hospital for five years and he is responsible for the maintenance of the ice machine quarterly. The CE stated he did not check the drain pipe connected to the ice machine and he had not seen the inside of the bottom cabinet until now. The CE confirmed the presence of black materials on the bottom cabinet sidings and flooring. He stated the black materials could be from water stain or water damage and added he was "unable to confirm or verify the presence of mold (a fungus) without further testing." The CE stated that this bottom cabinet should not be used for storage and had to be locked or be replaced. The CE said that the cabinet used to be a sink and he did not know whether the black materials had been there before. The CE added "it definitely needed to be replaced. I agree there should not have anything stored inside this cabinet."

In an interview on 7/18/17 at 2:45p.m., the DON stated that the black materials inside the bottom cabinet could be from water damage from the ice machine overflow or possibly from mold. The DON added there should not be anything stored in this cabinet.

The hospital was asked for and did not provide any policy and procedure for safe storage of supplies.

According to the Center for Disease Control:
"Mold will grow in places with a lot of moisture, such as around leaks in roofs, windows, or pipes, or where there has been flooding. Mold grows well on paper products, cardboard, ceiling tiles, and wood products. Mold can also grow in dust, paints, wallpaper, insulation, drywall, carpet, fabric, and upholstery."
"Exposure to damp and moldy environments may cause a variety of health effects, or none at all. Some people are sensitive to molds. For these people, molds can cause nasal stuffiness, throat irritation, coughing or wheezing, eye irritation, or, in some cases, skin irritation."
Reference: [https://www.cdc.gov/mold/dampness_facts.htm]

Based on observation, interview, and record review, for 4 (Patients 4, 17, 20, and 26) of 30 sampled patients, the hospital failed to maintain an effective infection control program to prevent the transmission and spread of infection.

1. An oxygen tank left in the hallway of an infected area was moved to an uninfected area without being disinfected.
2. Two staff entered the room of Patients 4 and 17, which had Strict Contact Precautions, without performing hand hygiene and donning Personal Protective Equipment.
3. Staff did not take precautions to apply gown and gloves and did not perform hand hygiene after touching equipment in a designated transmission-based precaution (Contact Precaution) room.
4. For Patient 20, staff removed a protective rubber stopper and plastic overwrap of a medication without using aseptic technique prior to withdrawal of the contents.
5. A visibly soiled pill crusher was used to crush medications administered to Patient 26 via a nasogastric feeding tube.

These failures had the potential for the transmission of infectious organisms to other patients.

1. Review of the hospital's P&P (policy and procedure) titled, "Cleaning of Shared Patient Medical Equipment" dated 5/2015, indicated the definition of Shared patient medical equipment included all equipment that is shared between patients. The P&P showed all equipment shall be cleaned and disinfected with a low level disinfectant (LLD).

During an initial tour observation of the hospital, on 7/17/17 at 9:30 a.m., an oxygen tank in a cart was sitting in the hallway of the hospital designated CRE (Carbapenem-resistant Enterobacteriaceae, a family of germs that are difficult to treat because they have high levels of resistance to antibiotics) unit. All of the patients in this unit were on Contact Precautions or Strict Contact Precautions (designed to reduce the risk of transmission micro-organisms by direct or indirect contact.)

During an observation and concurrent interview, at 9:35 a.m., the RN Supv (Registered Nurse Supervisor) 1 stated the oxygen tanks were stored in the ICU and RT (respiratory therapist) would use an oxygen tank for a patient who was to be transported to another area for a test or a procedure. RN Supv1 removed the oxygen tank and cart from the CRE unit and took it to the ICU (intensive Care Unit) without disinfecting the oxygen tank or the cart.

During an interview, on 7/19/17 at 9:55 a.m., RT3 stated oxygen tanks would be used to transfer a patient who was on a ventilator to the Radiology, OR (operating room) or if the patient was being moved from one room to another room. RT3 stated the Radiology or OR staff would usually bring an oxygen tank with them to transport a patient. RT3 stated everything on the CRE side stayed there or was cleaned with bleach wipes before moving it to another area. RT3 stated "It's CRE. You don't know if another RT is going to come take the tank or the caddy, for that matter."

In an interview, on 7/20/17 at 9:15 a.m., the ICRN (Infection Control Registered Nurse) and ICO (Infection Control Officer) confirmed an oxygen tank was considered to be shared medical equipment. The ICRN and ICO stated equipment left or used in the CRE unit should be wiped down with disinfectant before being moved to another unit.


2. Review of the hospital's P&P (policy and procedure) titled, "Transmission Based Precautions" dated 6/2017, indicated the following:
a. Transmission-Based Precautions are for patients with documented or suspected infection or colonization with epidemiologically important pathogens for which additional precautions are needed to prevent transmission. Transmission based precautions are interventions over and above Standard Precautions
b. Contact Precautions is a method designed to reduce the risk of transmission micro-organisms by direct or indirect contact. Contact Precautions are used for patients with known or suspected infections or evidence of syndromes that represent an increased risk of contact transmission including the presence of excessive drainage, fecal incontinence, or other discharges from the body suggesting an increased potential for extensive environmental contamination and risk for transmission.
c. For Contact Precautions, hand hygiene is the most important method of control to prevent transmission.

During an observation and concurrent interview, on 7/19/17 at 10:12 a.m., CNA (Certified Nurse Assistant)1 entered the room of Patient 4 and Patient 17 without performing hand hygiene and donning (putting on) PPE (Personal Protective Equipment.) A sign posted outside the door read, "Strict Contact Precautions." CNA1 stated she went in the room to leave diapers. At 10:20 a.m., RN Supv2 was seen entering the same room without performing hand hygiene and donning PPE. When questioned about entering the room, the RN Supv2 stated, "I didn't. I know I should. I'm a supervisor. I wasn't going to touch the patient."

During an interview, on 7/20/17 at 9:15 a.m., the ICRN explained "Strict Contact Precautions" was used to identify patients with CRE. The ICRN stated the use of PPE (gown, gloves and mask) listed on the signage for Strict Contact Precautions was required for all staff at all times.


32427

In an observation on 7/19/17 at 8:30 a.m., Contact precaution was established for a shared room, Room 413, with three patients documented or suspected of infection of Methicillin-resistant Staphylococcus aureus (MRSA), a type of bacteria resistant to many antibiotics, for which additional precautions were needed to prevent transmission.

#2a. During an observation, on 7/19/17, at 8:50 a.m., the Charge Nurse-Registered Nurse (CRN) 2 applied a condom catheter (male incontinence device that fits on the penis like a condom) for Patient 12. Without performing hand hygiene and changing the dirty glove, CRN 2 continued with the next procedure to wash Patient 12's face with a washcloth.

During an interview, on 7//19/17, at 9: 55 a.m., CRN 2 stated that he/she should have performed hand hygiene and put on new and clean pair of gloves after placement of the condom catheter and before washing Patient 12's face with the washcloth because there was a potential to "spread germs."

During an interview, on 7/20/17, at 1:20 p.m., the Infection Control Registered Nurse (ICRN) and Infection Control Officer were both informed of the observation. The ICRN and ICO verified that CRN 2 needed to perform hand hygiene and apply new gloves after the condom catheter procedure and before cleaning Patient 12's face with the washcloth.

Review of the policy, entitled, Hand Hygiene, with a release date 05/2015, it indicated, "moments for hand hygiene will be performed as follows...before a clean/aseptic procedure."

#2b. During an observation on 7/19/17, at 9:20 a.m., the Respiratory Therapist (RT) 1 entered Room 413 without wearing gown and gloves. The RT manipulated the call light plug, to stop the alarm, with his/her bare hand. The RT 1 exited the room without washing her/his hand or performing hand hygiene with the sanitizer outside the room. Room 413 was a designated "Contact Precaution" room and signage outside its door indicateing "gown and gloves for patient or environment contact...hand hygiene before and after contact..." Contact precaution was established for this shared room with three patients with documented or suspected infection (Methicillin-resistant Staphylococcus aureus (MRSA), a type of bacteria resistant to many antibiotics) for which additional precautions were needed to prevent transmission.

During an interview, on 7/19/17, at 9:50 a.m., the RT 1 stated that the facility practice prior to entering a room that indicated "Contact Precaution," was to put on gown and gloves. When RT 1was informed he/she was observed entering Room 413 without applying gown and gloves, the RT 1 stated it was an "error on my part." Also, the RT 1 stated that he/she was in the room to answer an alarm. The RT 1 stated that the alarm was from a patient's detached call light and he/she plugged the call light back into the socket. RT 1 was informed that he/she was observed doing this procedure with his/her bare hand and seen exiting the room without washing or performing hand hygiene. RT 1 stated that he could not remember if washed or sanitized his/her hand because he "usually" does it.

During an interview, on 7/20/17, at 1:20 p.m., the Infection Control Registered Nurse (ICRN) and Infection Control Officer were both informed of the observation. The ICRN and ICO verified that the facility practice for entering a "Contact Isolation" room is that everyone are required to put on gown and gloves, and that hand hygiene performed before and after entering/exiting the room.

Review of the document, entitled, "Transmission-Based Precautions," dated 05/2015, it indicated that procedures are executed based on the appropriate transmission based precautions and to post the appropriate precaution signage visible outside patient room. Further review of the document, indicated for rooms designated with "Contact Precautions,", hand hygiene is the most important method of control to prevent transmission, to use gloves, and to put on a gown whenever anticipating that clothing will have direct contact with potentially contaminated environmental surfaces or equipment in close proximity to the patient.

#2c. During an observation, on 7/20/17, at 1:30 p.m., the Licensed Vocational Nurse (LVN) 2, entered Room 413 without a gown, put on gloves to turn off an alarm, removed the gloves and exited the room.

During an interview, on 7/20/17, at 1:31 p.m. LVN 2 stated that he/she was supposed to put a gown on before entering the room; however, he/she was trying to turn off the alarm. LVN 2 confirmed she did not follow the instructions on the signage outside the door.

Review of the document, titled, "Transmission-Based Precautions," dated 05/2015, it indicated that procedures are executed based on the appropriate transmission based precautions and to post the appropriate precaution signage visible outside patient room. Further review of the document, indicated for rooms designated with "Contact Precautions," in putting on a gown whenever anticipating that clothing will have direct contact with potentially contaminated environmental surfaces or equipment in close proximity to the patient.


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4. A review of Patient 20's History and Physical (H&P), dated 3/31/17, showed she was an 78 year old admitted from a local hospital for management of respiratory failure resulting from pulmonary fibrosis pneumonia, kidney failure and other complicated medical problems. She was ventilator-dependent and had a type of gastrosotomy tube [Percutaneous Endoscopic Gastrostomy (PEG) tube] through which medications and nutrition were administered. [Reference: http://medical-dictionary.thefreedictionary.com/PEG]

A review of Patient 20's Physician's Orders showed she had a medication order dated 7/11/17 at 9:00 a.m., for Solu-Medrol 20 milligrams intravenous. Solu-Medrol is a steroid used to reduce inflammation.

On 7/17/17 at 9:20 a.m., during a medication pass observation and interview, a registered nurse (RN 2) prepared to administer a dose of Solu-Medrol to Patient 20. LVN 1 pressed the white plastic cap covering the rubber stopper which forced the diluent into the lower chamber. She dissolved the medication completely, and then removed the protective rubber stopper and entire white plastic overwrap. She did not attempt to remove the small inner perforated white plastic circle to expose the rubber port, and there was no rubber port remaining to disinfect. She said, "This vial is defective. I'll need to get another one from pharmacy." She obtained another vial from pharmacy and at 9:57 a.m. administered the dose to Patient 26 without first disinfecting the rubber stopper.

On 7/17/17 at 9:57 a.m. during an interview, RN 2 indicated she did not routinely swab or disinfect the rubber stopper with alcohol. She said, "I don't need to. It's sterile."

On 7/17/17 at 10:09 a.m. during a review of the manufacturer's product package insert (PPI) review and a concurrent interview with a staff pharmacist (RPH 1) he described the aseptic technique procedures for preparing a dose of Solu-medrol. He indicated the nurse should press the white plastic cap covering the rubber stopper to force the diluent into the lower chamber, dissolve the medication completely, remove the small inner perforated white plastic circle to expose the rubber port, disinfect the small port with alcohol then inject the needle into the port where indicated on the manufacturer's diagram on the product package insert. [Reference: Manufacturer's product package insert (PPI) instructions and diagram]. RPH 1 said, "Through the center - don't take the whole top off. We swab everything [with alcohol]. It's not sterile."

A review of the hospital's policy, titled, Administration of Medications via Injection, revised 6/2007, showed, "If medication needs to be drawn up into a syringe do so using aseptic technique."

A review of the directions for Solu Medrol administration from the manufacturer showed the following: "Press down on plastic activator to force diluent into the lower compartment. Gently agitate to effect solution. Remove plastic tab covering center of stopper. Sterilize top of stopper with a suitable germicide. Insert needle squarely through center of stopper until tip is just visible. Invert vial and withdraw dose." [Reference: PPI Pfizer, Oct 2016]

5. A review of Patient 26's face sheet showed she was a 60 year old admitted 7/8/17. Her History and Physical (H&P) dated, 7/8/17, showed she was admitted from a local hospital after sustaining injuries from a serious fall. She had a PEG tube.

On 7/17/17 at 9:20 a.m., during a medication pass observation and interview, LVN 1 prepared to administer a famotidine 20 milligram tablet. Famotidine is a histamine-2 blocker medication used to prevent gastrointestinal ulcers by decreasing the amount of acid the stomach produces. [Reference: daileymed.org] LVN 1 crushed the medications individually using a visibly soiled caked brownish stained disposable pill crusher. When asked what the brownish substance was, LVN 1 said, "It looks like a lot of medication that is stuck...Senna". Senna is a laxative.

On 7/17/17 at 9:25 a.m., during an interview, the Pharmacist-in-Charge (PIC) said, "It looks like a lot of medicine. It [the pill crusher] was too dirty to use. The pill crushers are disposable. Central supply has them. We store them on the unit... every unit. She should have gone and gotten a new one. He indicated using a pill crusher that was not clean placed the patient at risk for a preventable acquired infection as a result of direct contamination.

On 7/17/17 at 10:00 a.m., during an interview, the Senior Pharmacy Director (Sr Phar Dir) said, "I expect nursing staff to ensure supplies used during medication pass are cleaned prior to medication administration."

A review of the hospital's procedure, titled, Medication Administration-Audit Tool, revised 6/2017, showed, "Clean pill crusher prior to each use and verify label with patient name if for single use patient."




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Based on observation, interview, and record interview, the facility failed to ensure the establishment and implementation of a plan of care for impaired mobility for one of 31 patients (Patient 6). For Patient 6, this failure resulted in decreased activity and increased emotional distress.

Findings:

A review of Patient 6's History and Physical dated 5/17/17 reflected an admission for treatment of respiratory distress and rehabilitation to improve physical strength and performance of activities of daily living (ADLs).

During an observation and concurrent interview on 7/17/17 at 9:53 a.m., Patient 6 was semi-recumbent in bed, with a high flow oxygen supply provided through tubing beneath his nostrils. Patient 6 said he needed assistance to get out of bed and to walk; he should have been receiving exercise assistance five days a week, but he had not received it enough times last week. Patient 6 said he needed to receive his exercises so that he could improve his walking and general condition enough to transfer out of the facility. Patient 6 said it made him angry to not receive the exercise he needed.

During an interview and record review 7/17/17 at 3:15 p.m., Restorative Nurse Assistant 1 (RNA 1) confirmed Patient 6 only received RNA treatments on 7/10/17, 7/12/17, and 7/14/17 for the week of 7/10/17 to 7/17/17.

A review of Patient 6's Physical Therapy (PT) Notes dated 5/18/17, by Physical Therapist 1 (PT 1) reflected the recommended plan of care was for PT five times per week for general muscle weakness, and to improve performance in walking and activities. The PT Notes by PT 1 dated 6/30/17 reflected, "Pt [patient] has shown slow and steady progress with skilled PT interventions, motivated to participate ...Pt put on hold as per MD [doctor] order because of change in condition, as pt desaturates [oxygen level in the body decreases, causing shortness of breath and activity intolerance] with activities now more as compared to earlier. Pt is discharged from the skilled therapy as of now." The PT Notes dated 7/7/17 reflected PT 1 completed an evaluation of Patient 6, and recommended no skilled PT due to continued desaturation with activity, but for Patient 6 to have exercise provided by the Restorative Nurse Assistant (RNA) program.

During an interview and concurrent record review on 7/18/17 at 8:33 a.m., PT 1 confirmed there had been no documented care plan for impaired mobility from 7/10/17 to 7/18/17. PT 1 said after a patient evaluation for physical therapy, the physical therapist was responsible for writing recommendations, including making or updating the plan of care. PT 1 said she had not known she was responsible for making the care plan for the RNA program; she thought she just needed to write instructions for the RNA's. PT 1 confirmed she had not documented specific instructions such as number of times per week for exercises or types of exercises from 7/10/17 to 7/18/17.

During an interview 7/18/17 at 8:05 a.m., Director of Rehabilitative Services (DRS) said the RNA's worked under the direction of the Physical Therapy Department, and depended on the physical therapist recommendations to determine type and amount of exercise needed by a patient. During an interview 7/17/17 at 3:10 p.m., DRS said Patient 6 desaturated too much for active physical therapy, but he was so motivated to exercise and maintain his status, he needed to get exercise five times per week.

A review of Physician Orders reflected an order for PT evaluation and treatment dated 7/6/17. The Physician Progress Note dated 7/10/17 reflected, "Patient should continue to get PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy)."

A review of, "The Organization Plan for the Provision of Patient Care, Treatment, and Services," dated 2/17/17, indicated, "Each patient has a plan of care. An interdisciplinary approach is utilized, as appropriate to promote continuity of care. Physical needs of the patient are attended to through interventions to achieve an optimal health outcome. Each patient is provided an environment that promotes safety and psychosocial well-being."

The facility policy, "Assessment/Re-Assessment-Interdisciplinary Patient," dated reviewed 10/2016, indicated the licensed physical therapist was responsible for the initial evaluation, treatment plan, and goals. The policy further indicated a reassessment, and documentation of the reassessment, should occur every two weeks, or whenever the patient had a significant change in status.

The facility policy, "General Documentation Guidelines," released 6/2017 reflected, "to facilitate consistency and continuity in patient care, the medical record contains very specific data and information including: goals of treatment and the treatment plan."