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On the days of the Recertification Survey based on observation, interview and clinical record review, the Hospital failed to ensure the nutritional needs of patients by not having an organized dietary service that has oversight in the hospital's Quality Assurance and Performance Improvement (QAPI) or Infection Control programs, has no hospital policies and procedures that address the availability of diet manuals in the hospital, accommodation of non- routine occurrences such as parental nutrition, total parenteral nutrition, peripheral parenteral nutrition, changes in diet orders, early/late trays, nutritional supplements, etc.. There were no policies and procedures for acceptable hygiene practices of food service personnel or guidelines for kitchen sanitation found on the hospital premises. The hospital had no current therapeutic diet manual approved by Medical Staff and the contracted Dietician. The Hospital failed to ensure that the contracted Dietician provided supervision for the nutritional aspects of patient care and was available to consult with patients and submit a timely report that could be utilized by other health care providers, and did not provide ongoing patient nutritional assessments to ensure that appropriate interventions were made in response to the nutritional need of swing bed patients.

The findings are:

Cross Reference to A 0619: The hospital failed to ensure that food and dietetic service requirements were met in that the hospital provided no oversight of the dietetic system via an internal Quality Assurance and Process Improvement (QAPI) or an Infection Control program, failed to monitor the hospital's system for initiating patient referrals for nutrition consults through its screening process, failed to monitor the effectiveness of its dietary consultation program, and failed to establish hospital policies and procedures for the dietary and dietetic programs.

Cross Reference to A 0621: The Hospital failed to ensure that the contracted dietician was available to supervise the nutritional aspects of patient care for the hospital and for 1 of 1 hospitalized patient (Patient #14) who had received a dietary consult and for 3 of 3 swing bed admissions who never received a dietary consult. (Resident #1, #2, and #3)

Cross Reference to A 0628: The hospital failed to ensure that its dietary services were monitored to ensure that patient trays were delivered in a safe manner, and that patient satisfaction issues were assessed and monitored through an effective Quality Assurance and Process Improvement (QAPI) program to ensure the quality of its food and nutrition.

Cross Reference to A 0630: The hospital failed to ensure that patient nutritional needs were met in accordance with recognized dietary practices for 2 of 5 concurrent patient records reviewed (Resident #1 and Patient #13) and for 4 of 4 closed patient records reviewed where needed services was or was not identified and the patients did not receive the services. (Resident #2 and #3 and Patient #14)

Cross Reference to A 0631: The Hospital failed to have a current therapeutic diet manual that was available to the medical and nursing staff that was approved by the dietician and medical staff.

On the days of the Recertification Survey based on observation, interview, and review of facility records, the Governing Body failed to monitor problems and monitor utilization of its delivery of Dietary Services to patients provided under contract with a potential to impact all patients in the hospital who might require the care and services from the hospital's dietetic department.

The findings are:

Cross Reference to A0619: The hospital failed to ensure that food and dietetic services organization were met in that the hospital provided no oversight of the dietetic system via an internal Quality Assurance and Process Improvement (QAPI) or an Infection Control program, failed to monitor the hospital's system for initiating patient referrals for nutrition consults through it screening process, failed to monitor the effectiveness of its dietary consult program, and failed to establish hospital policies and procedures for the dietary and dietetic programs.

On the day of the Recertification Survey based on observation, staff interview, and record review, the hospital failed to ensure services performed under the hospital's contract for the Dialysis Department for maintenance and culturing of 4 of 4 dialysis machines and in the Dietary Department related to the hospital's failure to establish policies and procedures for dietary services, referrals for dietary consults, and no oversight via the hospital's QAPI (Quality Assessment and Process Improvement) and Infection Control programs in that those contracted services for obtaining and monitoring dialysis machine maintenance and cultures were performed in a safe and effective manner with a potential to affect all patients receiving dialysis treatment, or requiring dietary oversight for its dietary services.

The findings are:

On 6/21/2010 at 1330, a review of the Dialysis Department Station records for machine cultures showed the hospital had no documentation that four (4) dialysis machines had machine cultures collected or the results of any cultures for April 2010 and May 2010. There was no documentation that the RO (Reverse Osmosis) system was disinfected with Renalin during May 2010 by the contracted Biomedical Technician. The findings were verified by the Dialysis Nurse Manager at 1330 on 6/21/10. The Hospital was unable to obtain the necessary documentation of the machine cultures from the biomedical technician who performed the cultures and disinfection until 6/23/2010. The Hospital provided the Surveyor with a signed contract from ".... Healthcare" as the provider of dialysis machine maintenance but no dialysis machines were listed as part of the current list of inventory to be maintained. The findings were verified by Chief Nursing Officer on 6/23/2010.

Cross Reference to A 0619: The hospital failed to ensure that the food and dietetic service organization was met in that the hospital provided no oversight of the dietetic system via an internal Quality Assurance and Process Improvement (QAPI) or an Infection Control program, failed to monitor the hospital's system for initiating appropriate patient referrals for nutrition consults through it screening process, failed to monitor the effectiveness of its dietary consult program, and failed to establish hospital policies and procedures for its dietary and dietetic programs.

On the day of the Recertification Survey based on random observations, record review, and staff interviews, the facility failed to provide a safe setting for patients by not having a functioning call light system in the all Patient Treatment Areas with a potential to affect all patients treated in the Emergency Department, the Post Anesthesia Care Unit (PACU), and the Outpatient surgery bays, and by not obtaining and reviewing the monthly disinfection and cultures reports on four (4) of four (4) Dialysis machines and the Reverse Osmosis (RO) system.

The findings are:

On 6/21/2010 at 1330, a review of the Dialysis Station records for machine cultures revealed the hospital had no written documentation that four (4) of 4 dialysis machines had cultures collected and that the results were within the normal range for April 2010 and May 2010. There was no documentation that the RO system was disinfected with Renalin in May 2010. There was no documentation that the Medical Director or Nurse Manager reviewed the culture reports for April 2010 and May 2010 or the RO Loop disinfection report for May 2010. The findings were verified by the Dialysis Nurse Manager who reported that a copy of the cultures reports should have been obtained and the results of the machine cultures should have been reviewed by the facility.

On 6/21/2010 at 1400, during the tour of the Emergency Department (ED), observations revealed there were no call lights in any of the patient examination areas including one patient room with a closed door. On 6/21/10 at 1400, ED Registered Nurse (RN) #1 verified there was no call light system in the ED except for one patient bathroom in the treatment area. RN #1 reported that if a patient needed help, the patient could call out for assistance since four of the five treatment areas only had curtains for privacy. The fifth treatment area was a room with a door. RN #1 reported that patients are never left alone in this room. During random observations on 6/21/2010 at 1445 and on 6/23/2010 at 1100, the examination room door was closed, and no ED staff were observed in the room with the patient occupant in the room. Observation did reveal a call light was functioning in the one patient bathroom in the ED treatment area but when the call light was tested, the audio portion of the alarm sounded around the corner in the surgical area. RN #1 stated that when the alarm sounded in the surgical area, someone would call the ED to let ED staff know the call system was ringing. On 6/22/2010 at 1035, the Emergency Department Nurse Manager confirmed there were no call lights in the patient treatment areas in the ED and in the waiting room bathroom. The lack of an effective call system has the potential to cause harm should a patient need immediate medical assistance and is unable to call out for help.

Hospital Policy K-21, reads, " ... The Dialysis unit will monitor the reverse osmosis water and dialysate from each of the machines on a monthly basis. Water will be tested for Colony Forming Units (CFUs) and Lymphocytic Amoebocyte Lysate (LAL). Dialysate will be tested for CFUs. All testing will be done per current AAMI (Association for the Advancement of Medical Instrumentation) standards. "



28552

On 06/22/10 at 1430, during a tour of the same day surgery department with the Clinical Manager, observation of the patient area revealed that 4 of 4 of the patient treatment areas had inoperable call lights in the rooms. Observation of the patient areas in the Recovery Room showed that two of two patient rooms had inoperable call lights. During the observation period, the hospital Maintenance Director made some adjustments to the call light system in one of one patient areas but although the system alerted the nurse desk, the light over the patient's door and in the patient's room failed to light up. The finding was confirmed on 06/23/10 at 1430 by the hospital Maintenance Director and the Clinical Manager on 06/23/10 at 1500.

On the day of the Recertification Survey based on record review and staff interview, the facility failed to ensure that one (1) Supervisory Staff Nurse had the required current certification in Advanced Cardiac Life Support (ACLS) and that the Nurse in the dialysis unit had signed and dated physician orders for the administration of Heparin during the patient's dialysis treatment for three (3) of five (5) patients whose dialysis treatment sheets were reviewed for care and services (Patient #5, #6, and #7), and one of one patient whose nutritional assessment was inaccurate relative to data obtained from the patient's initial nursing assessment and resulted in the failure of the patient to receive a nutritional follow up. (Patient #13).

The findings are:

On 6/22/10 at 0900, a review of Patient #7's dialysis treatment sheet for 6/18/2010 revealed the 36 year old with a diagnosis of End Stage Renal Disease received a total of 1900 units of Heparin during dialysis and 1000 units of Heparin into each catheter limb after the dialysis treatment. There was no signed physician's order for Heparin on the Physician's Dialysis Order sheet for 6/18/2010. The finding was confirmed by the Dialysis Nurse Manager on 6/22/2010 at 0900.

On 6/22/2010 at 0930, a review of Patient #6's dialysis treatment sheet for 6/16/2010 showed the 75 year old with a diagnosis of Kidney Failure received a total of 800 units of Heparin during the patient's dialysis treatment. There was no signed physician order for Heparin on the Physician's Dialysis Order sheet for 6/16/2010. The finding was confirmed by the Dialysis Nurse Manager on 6/22/2010 at 0930.

On 6/22/2020 at 1000, a review of Patient #5's dialysis treatment sheet for 6/10/2010 showed the 71 year old with Kidney disease received 1000 units Heparin (total 2000 units) administered into each limb of the patient's central catheter. There was no signed physician order for Heparin on the Physician's Dialysis Order sheet for 6/10/2010. The finding was confirmed by the Dialysis Nurse Manager on 6/22/2010 at 1000.

Hospital Policy Number C-20, reads, "Subject Administration of Heparin. Purpose: Provide adequate heparinization for the patient during dialysis. Policy: Heparin shall be administered a per physician's order. Heparin used should be 1000 units/ml (milliliter). "

On 6/22/2010 at 1500, a review of the hospital training records revealed the Nurse Manager of the Emergency Department (ED) who, at times, also supervised the Medical Surgical Floor with telemetry (heart monitor) beds did not have a current certification in Advanced Cardiac Life Support (ACLS) as required per hospital policy. The ED Nurse Manager's ACLS certification expired in November 2008. The finding was verified on 6/23/2010 by the Chief Quality Officer.

Hospital Job Description, signed by the Emergency Department Nurse Manager, read,: ".... Qualifications: 1. Licensure, Certification: a. Licensed to practice as a Registered Nurse in the State of South Carolina. b. Current Basic Life Support. c. Current Advanced Cardiac Life Support ... ".


27544

On 06/22/10 at 1400, clinical record review of Patient #13's chart showed the patient was admitted on 06/20/10 with a diagnosis of Urinary Tract Infection not otherwise specified(NOS) decubitus ulcers at stage 2, and a previous hospitalization for failure to thrive .
On 6/22/10 at 1400, a review of the patient's chart showed a hospital form, titled, Initial Interview, dated 06/20/10, that read, " ... previous hospitalization for failure to thrive, patient dependent, and total care needed for activities of daily living. The section identified for the neurological assessment revealed the patient "is oriented to person, follows simple commands only." The Injury Risk Assessment showed the patient "disoriented at all times, nutritional status eats/drinks 50% or less of each meal...". However, review of the "nutritional screen" dated 6/20/10 in the patient's chart showed the nurse assessed the patient as "has no difficulty in feeding self" and then, the nurse recorded the patient's assessment score as a "0". Due to the nurse's failure to assess all the pertinent data recorded in the patient's initial nursing assessment relative to nutritional status, Patient #13 was not referred for a nutritional consult. Review of a form, titled, Problem Activity, dated 06/20/10 in the patient's chart, read, ".... size of the wound: 3 Stage 2 areas noted to coccyx area. 1 was 1/2 x 1/2 centimeter (cm). 2nd area was 1 cm x 1 cm and 3rd area was 1 cm x 2 cm...". Review of the patient's Clinical Record revealed a form, titled, Graphic and Intake/Output that had a section for recording the Patient Diet and Percent Consumed that was blank. On 06/22/10, a review of hospital records and other data revealed there was no hospital policy and procedure for a referral for nutritional assessment for at risk patients. The findings were confirmed with Registered Nurse #14 on 06/22/10 at 1200. On 06/24/10 at 0950, the Chief Quality Officer revealed that although the hospital had deleted the wound classification as a guideline for calling a dietary consult, the hospital had not initiated any new or revised policies and procedures that addressed a referral for nutritional assessments or nutritional consults.

On 06/23/10 at 1400, a review of hospital records and other data revealed a review form, titled, Skin Assessment Protocol, dated 07/19/96 and reviewed 05/23/01, reads, "..5. Patients with a Stage ll or greater should have a consult initiated with the Physical Therapist (must obtain physicians order,) and Dietary...".

On the days of the Recertification survey based on record reviews, interviews, and review of policy and procedure, the facility failed to complete an initial assessment for one of one open swing bed records reviewed. (Resident #1), and failure to accurately assess one of two patients accurately using the nutritional screen based on data obtained from the initial nursing assessment. (Patient #13)


The findings are:

On 6/21/10 at 1430, review of Resident #1's open medical record revealed the sixty-year old was admitted with diagnoses of Dementia , Peri-rectal Abscess and Dehydration. The patient's admission assessment, dated 3/26/10, revealed staff documented poor skin integrity but had no documentation of ulcer or lesion wound measurements. The "Patient Progress Notes", dated 3/26/10 at 2132, revealed staff documented bilateral heel and left buttock ulcers. Progress notes, dated 3/27/10, revealed staff documented a Stage 3 ulcer with serous drainage. Progress notes on 3/28/10 showed staff documented a Stage 2 ulcer to both ankles that was approximately the size of a quarter. There was no documentation of an initial wound measurement.

Review of Hospital Policy PC 2009.08, "Patient Assessment and Reassessment", read, Purpose: To outline the criteria and time frames for patient assessment/reassessment. GOAL AND PROCESSES: A. The goal of patient assessment is to determine the necessary care or treatment through the assessment of each patient's needs. In order to achieve this goal, the following processes must be completed...Policy: A patient will be initially assessed by a Registered Nurse in each area where nursing care is provided and by other qualified healthcare professionals from other disciplines participating in his/her care...".

Review of Hospital Policy "Skin Assessment Protocol", reviewed 5/23/01, read, "Purpose: To establish guidelines for identification of individuals at risk for development of skin breakdown and prevention or management of skin breakdown. POLICY: 1. A systematic skin assessment shall be performed on all patients admitted ...Patients with a Stage II or greater should have a consult initiated ... Dietary...".

Review of Hospital Policy "Wound Staging and Measurement Protocol", read, "...Clinical Assessment and Care: 1. On admission, a full head-to-toe physical assessment of skin condition is to be performed...4. Documentation of all pressure ulcers will occur on the Skin Assessment...5. Documentation of pressure ulcers will include: a. Location of pressure ulcer b. Stage c. Measurements: Length x width x Depth...".






27544

On 06/22/10 at 1400, clinical record review of Patient #13's chart showed the patient was admitted on 06/20/10 with a diagnosis of Urinary Tract Infection not otherwise specified(NOS) decubitus ulcers at stage 2, and a previous hospitalization for failure to thrive .
On 6/22/10 at 1400, a review of the patient's chart showed a hospital form, titled, Initial Interview, dated 06/20/10, that read, " ... previous hospitalization for failure to thrive, patient dependent, and total care needed for activities of daily living. The section identified for the neurological assessment revealed the patient "is oriented to person, follows simple commands only." The Injury Risk Assessment showed the patient "disoriented at all times, nutritional status eats/drinks 50% or less of each meal...".
Review of the patient's "nutritional screen" dated 6/20/10 in the patient's chart showed the nurse assessed the patient as "has no difficulty in feeding self" and then, the nurse recorded the patient's assessment score as a "0". Due to the nurse's failure to assess all the pertinent data recorded in the patient's initial nursing assessment relative to the patient's nutritional status, Patient #13 was not referred for a nutritional consult. Review of a hospital form, titled, Problem Activity, dated 06/20/10 in the patient's chart, read, ".... size of the wound: 3 Stage 2 areas noted to coccyx area. 1 was 1/2 x 1/2 centimeter (cm). 2nd area was 1 cm x 1 cm and 3rd area was 1 cm x 2 cm...". Review of the patient's Clinical Record revealed a hospital form, titled, Graphic and Intake/Output that had a section for recording the Patient Diet and Percent Consumed that was blank.
On 06/22/10, a review of hospital records and other data revealed there was no policy and procedure for a nutritional assessment for at risk patients. The findings were confirmed with Registered Nurse #14 on 06/22/10 at 1200. On 06/24/10 at 0950, the Chief Quality Officer revealed that although the hospital had deleted the wound classification as a guideline for calling a dietary consult, the hospital had not initiated any new or revised policies and procedures that addressed referral for nutritional assessments or nutritional consults.
On 06/23/10 at 1400, a review of hospital records and other data revealed a review form, titled, Skin Assessment Protocol, dated 07/19/96 and reviewed 05/23/01, reads, "..5. Patients with a Stage ll or greater should have a consult initiated with the Physical Therapist (must obtain physicians order,) and Dietary...". On 06/22/10, Registered Nurse #11 revealed that patients are reassessed every day for nutritional status but there was no time frame for reassessing patients using the scoring method to implement interventions. The score on the nutritional assessment determines guidelines for interventions, and a score of 6 or higher would place the patient in a high risk and a referral for a dietary consult.

On the days of the Recertification Survey based on clinical record review and interview, the Hospital failed to ensure that the nursing care plan was kept current by ongoing nutritional care plans and interventions to meet the patients needs for 1 of 1 concurrent patient records reviewed for dietetic services (Patients #13) and 1 of 1 closed patient records for dietetic services (Patient #14) and 1 of 1 concurrent review of a swing bed resident for dietetic services. (Resident #1)

The findings are:

On 06/22/10 at 1400, clinical record review of Patient #13's chart showed the patient was admitted on 06/20/10 with a diagnosis of Urinary Tract Infection not otherwise specified(NOS) decubitus ulcers at stage 2, and a previous hospitalization for failure to thrive .
On 6/22/10 at 1400, a review of the patient's chart showed a hospital form, titled, Initial Interview, dated 06/20/10, that read, " ... previous hospitalization for failure to thrive, patient dependent, and total care needed for activities of daily living. The section identified for the neurological assessment revealed the patient "is oriented to person, follows simple commands only." The Injury Risk Assessment showed the patient "disoriented at all times, nutritional status eats/drinks 50% or less of each meal...". Review of a form, titled, Problem Activity, dated 06/20/10 in the patient's chart, read, ".... size of the wound: 3 Stage 2 areas noted to coccyx area. 1 was 1/2 x 1/2 centimeter (cm). 2nd area was 1 cm x 1 cm and 3rd area was 1 cm x 2 cm...". However, review of the "nutritional screen" dated 6/20/10 in the patient's chart showed the nurse assessed the patient as "has no difficulty in feeding self" and then, the nurse recorded the patient's assessment score as a "0". Due to the nurse's failure to assess all the pertinent data recorded in the patient's initial nursing assessment relative to nutritional status, Patient #13 was not referred for a nutritional consult. Review of the patient's Clinical Record revealed a form, titled, Graphic and Intake/Output that had a section for recording the Patient Diet and Percent Consumed was blank. There was no documentation of assessment of nutritional needs interventions to assists patient at meal time and monitor food intake on Intake and Output clinical record. On 06/23/ 10 at 1100, the findings were confirmed with Registered Nurse #14.

On 06/23/10 at 1430, review of the closed Clinical record of Patient #14 showed the patient was admitted on 01/08/10 with a diagnoses of Atrial Fibulation with Rapid Ventricular Response and Diabetes uncontrolled. Review of the Graphic record and the Intake and Output record showed " patient diet and percent consumed..." had only 1 entry for the day shift on 1/10/2010 the showed 25% of patient's diet was consumed. Review of the initial nutritional screen showed the nurse assessment of the patient's nutritional assessment resulted in a score of more than 6 and a dietary consult was ordered. Review of Patient #14's plan of care showed the patient's plan of care had no interventions on the nursing care plan to monitor and record the patient's food intake.




21307

On 6/21/10 at 1430, a review of Resident #1's open medical record revealed the sixty-year old was admitted with diagnoses of Dementia, Peri-Rectal Abscess and Dehydration. The patient's admission assessment, dated 3/26/10, showed staff documented poor skin integrity. The "Patient Progress Notes", dated 3/26/10 at 2132, showed staff documented bilateral heel and left buttock ulcers. The diagram to indicate wound location showed four ulcers: one on each heel and two on the left buttock. Progress notes, dated 3/27/10, showed staff documented a Stage 3 ulcer with serous drainage. Progress notes on 3/28/10 showed staff documented a Stage 2 ulcer to both ankles, approximately the size of a quarter. There was no documentation of an initial wound measurement for any of the ulcers. "Patient Progress Notes", dated 3/26/10 at 2114, showed staff documented that the patient ate 25%-50% of most meals. Progress notes, dated 3/27/10, showed staff documented a Stage 3 ulcer with serous drainage, and dietary intake of 25% or less of most meals. There was no documentation in the patient's chart that a nutritional consult per hospital policy was requested or done. Progress notes on 3/28/10 showed staff documented a Stage 2 ulcer to the patient's ankles approximately the size of a quarter. There was no documentation in the patient's record of a dietary consult. Review of the "Problem Activity' record, (patient's plan of care), dated 3/27/10, in the section for wound assessment showed skin treatments interventions selected by staff included turning/positioning program and heel protectors. The nutrition or hydration interventions selected by staff to manage the patient's skin problems was ulcer care. There were no interventions selected by staff to monitor the patient's intake and output or for a nutritional consult.

On the day of the Recertification survey based on observation, data review, and interviews, the hospital failed to ensure that a Registered Nurse assigned nursing care of each patient to other nursing personnel in accordance with the patient's needs and the competence of the available nursing staff in the Emergency Department, Same Day Surgery, and Operating Room.

The findings are:

On 6/21/2010 at 1430, observations in the Emergency Department (ED) revealed there was no daily staff assignment sheets available for review. At the time of the observation, there were two Registered Nurses (RN) and one ED Technician on duty. There were five (5) treatment areas or bays in the ED and all of the treatment bays were occupied by patients. RN #1 reported that no staff assignments were made in the ED, and patient triage was done by any RN who was not busy at the time of a patient's arrival to the ED, and patient care was conducted with assistance from the ED Technician. The findings were verified by the ED Nurse Manager on 6/22/10 at 1045.


28552

Observation on 6/22/10 at 1430 in the same day surgery suite and the operating room revealed there were no written patient assignments for staff . The Clinical Manager verified the findings on 6/22/10 at 1430.

On the days of the Recertification Survey based on observation and interview, the hospital failed to ensure that medical records were protected from fire and and water damage in the external medical record storage building and in medical record storage areas located in the main hospital building.

The findings are:

On 06/24/10 at 0930, observation of the radiology films storage revealed that the the radiology films are stored in a building outside the hospital. Observation of the storage building revealed the entrance to the room had a large amount of very shallow water that had leaked into the room. The finding was confirmed with Radiology Technician (RT) #1. RT #1 was not able to locate a fire extinguisher in the storage room or another room that was located in the building.


27175

During a tour of the medical records area on 6/23/10 at 0930, observations in the main medical records office revealed an area of brown warped ceiling tiles adjacent to the air conditioning unit indicating water leakage. In a medical records storage area located near the physician lounge observations showed an area of brown warped ceiling tiles adjacent to the air conditioning unit, the carpet beneath the air conditioning unit was water stained, and the shelves on which the records were stored were approximately 1/4 - 1/2 inch from the floor. The findings were verified by the Director of Health Information Management on 6/23/10 at 1030.

On the days of the Recertification survey based on record review and facility policy and procedure review, the hospital failed to ensure that all patient records are authenticated, signed, and dated by the practitioner for 1 of 17 closed patient records reviewed (Patient #8 and #1) and 1 of 1 concurrent swing bed record reviewed for care and services. (Resident #1)

The findings are:

A clinical record review conducted on 6/23/10 at 1125 revealed Patient #8, admitted to the facility on 5/6/10 and discharged on 5/7/10 with the diagnosis of Paroxymal Atrial Fibrillation, Asthma, and End Stage Renal Disease. Form # BCHNC407, titled, "Bamberg County Hospital Interdisciplinary Progress Notes", dated 5/7, was not signed or timed by the physician.

Facility Policy, titled, "Medical Record Documentation Standards", states, "...Responsibility:...Procedure:...3. All medical record entries shall be legible and shall contain the date, time of when the entry was prepared...13. It shall be the practitioner's responsibility to ensure that all entries in the medical record are dated, timed and the author identified. 14. Entries requiring medical opinions are only documented by licensed physicians...Authentication: All reports contained in the medical record shall be authenticated by the responsible individual to ensure the reliability of the contents. 1. Authentication shall take the form of complete signature by the originator, Initials will not be accepted. 2. Signature stamps may not be used; unless it is under signature of MD. 3. All other professionals, such as consulting physicians, ancillary professional staff, Social service and nursing shall sign, date, and time all reports they originate. 4. Documentation by other individuals so authorized by the medical staff, but who do not have clinical privileges must be countersigned by the attending physician according to their credentialing scope of privilege. 5. All physician orders must be signed, dated, and timed by the physician...".




21307

On 6/21/10 at 1430, a review of Resident #1's open medical record revealed the sixty-year was old admitted with diagnoses of Dementia, Peri-Rectal Abscess and Dehydration. The Progress Notes dated 4/4/10, 4/5/10, 4/10/10, 4/16/10, 5/1/10, 5/7/10, 5/15/10, 5/16/10, 5/30/10 did not include the time of the entries.

On the days of the Recertification Survey based on record review, interview and hospital policy review, the hospital failed to ensure all physician orders were signed, dated, and timed within 30 days of the patient's discharge, and all verbal orders were signed, dated, and timed within 48 hours for 4 of 17 closed records reviewed. (Patient #1, 8, 10, and 11)

The findings include:

A clinical record review conducted on 6/22/10 at 1340 revealed Patient #1 was admitted to the facility on 3/6/10 and discharged on 3/7/10 with the diagnosis of Hyperglycemia. Telephone Physician Orders written on 3/6/10 and 3/7/10 were not dated and timed by the physician within 48 hours of being taken or within 30 days of discharge.

A clinical record review conducted on 6/23/10 at 1125 revealed Patient #8, was admitted to the facility on 5/6/10 and discharged on 5/7/10 with the diagnosis of Paroxymal Atrial Fibrillation, Asthma, and End Stage Renal Disease. Physician Telephone Orders written on 5/7/10 were not signed, dated, and timed by the physician within 48 hours of being taken or within 30 days of discharge.

A clinical record review conducted on 6/23/10 at 1245 revealed Patient #10, was admitted to the facility on 4/17/10 and discharged on 4/21/10 with the diagnosis of Diabetes with Peripheral Circulation, Type 2. A physician telephone order written on 4/17/10 was not signed, dated, or timed by the physician within 48 hours of being taken and within 30 days of discharge.

A clinical record review conducted on 6/23/10 at 1310 revealed Patient #11, was admitted to the facility on 3/14/10 and discharged on 3/16/10 with the diagnosis of Acute Myocardial Infarction. A physician verbal order written on 3/16/10 was signed, dated, and timed by the physician on 4/20/10 which was greater than the 48 hour authentication timeframe, as well as greater than the 30 day discharge timeframe.
The findings were verified by the Director of Health Information Management on 6/23/10 at 1600.

Hospital Policy, titled, "Medical Record Documentation Standards" reads, "...Authentication: All reports contained in the medical record shall be authenticated by the responsible individual to ensure the reliability of the contents. 1. Authentication shall take the form of complete signature by the originator, Initials will not be accepted. 2. Signature stamps may not be used; unless it is under signature of MD. 3. All other professionals, such as consulting physicians, ancillary professional staff, Social service and nursing shall sign, date, and time all reports they originate. 4. Documentation by other individuals so authorized by the medical staff, but who do not have clinical privileges must be countersigned by the attending physician according to their credentialing scope of privilege. 5. All physician orders must be signed, dated, and timed by the physician...Orders: Timeliness: Orders shall be written as needed. Telephone and verbal orders shall be authenticated and dated by the responsible physician according to the Medical Staff Bylaws. Content: All orders shall be signed and dated by the originating physicians. Only individuals authorized in the medical staff rules and regulations may record verbal orders from physicians on the medical staff. All patients discharged must have written discharge order signed by the physician or physician-on-call in cases of stat transfers".

Hospital Policy #4004, "INCOMPLETE MEDICAL RECORDS", reads, "POLICY: *Medical records shall be completed within 30 days of the patient's discharge. *Medical records shall be completed promptly and authenticated or signed by a physician, dentist or podiatrist within 30 days following a patient's discharge. *The records of discharged patients are completed within a period of time that in no event exceeds 30 days following discharge...".

On the days of the Recertification survey based on record review and interview, the hospital failed to ensure that all consults are completed and the authenticated consult was documented in the patient's clinical record records reviewed for care and services for 1 of 17 closed patient records reviewed. (Patient #10)

The findings are:

A clinical record review conducted on 6/23/10 at 1245 revealed Patient #10 was admitted to the facility on 4/17/10 and discharged on 4/21/10 with the diagnosis of Diabetes with Peripheral Circulation, Type 2. On 4/19/10, a consult was ordered to see the patient related to the patient's right big toe. There was no consultation report contained within the patient's medical record. The findings were verified by the Director of Health Information Management on 6/23/10 at 1600.

Hospital Policy titled, "Medical Record Documentation Standards", reads, "...Consultations: Specialized evaluations shall be ordered only by the attending physician. There must be a written order for the evaluation on the patient's chart. a. Consultation reports shall be required on all cases, where the diagnosis is obscure or when there is a doubt as to the best therapeutic measures to be utilized. b. Physician Documentation Guidelines: a. The request and need for a consultation must be documented. A record of a written or verbal consultation request must specify whom the request is from and the reason for the request. b. The consultant's opinion as well as any services ordered or performed must be documented in the patient's medical record. Documentation must meet CPT guidelines for the consultation code selected. c. The results of the consultation must be reported to the requesting physician or other appropriate source and a copy retained in the Bamberg County Hospital patient record. d. The consulting physician must complete all elements of the required elements".

On the days of the Recertification Survey based on medical record review and staff interview, the facility failed to ensure the proper execution of informed consent for Hemodialysis and Percutaneous Endoscopic Gastrostomy (PEG) tube placement for 2 of 17 closed record and that the consent forms did not include the physician signatures on the consent form, or confirmation of the identity of patient representative signing the consent for the patient. (Patient #8 and 16)

The findings include:

A clinical record review conducted on 6/23/10 at 1125 revealed Patient #8 was admitted to the facility on 5/6/10 and discharged on 5/7/10 with the diagnosis of Paroxymal Atrial Fibrillation, Asthma, and End Stage Renal Disease. The hospital form, titled, "Bamberg County Hospital/Consent for Procedure" dated 5/7/10 for Hemodialysis was not signed, dated, and timed.

Hospital Policy titled, "CONSENT FOR OPERATIONS AND OTHER PROCEDURES", revised 4/03 and 6/08, reads, "...PROCEDURE: A. The consent for shall be completed and include the following per physician's order: *Date and time consent signed *Name of physician performing surgery/procedure(s) *Name of patient *Authorization for blood transfusion *Signature of patient or person authorized to consent and the relationship to the patient *Signature of witness(es) *Signature of surgeon...".



27544

On 06/23/10 at 1400, a review of Patient #16's chart showed the patient was admitted on 02/27/10 with a diagnosis of Cancer. Review of the patient's record revealed that patient's representative had signed a consent for treatment on 03/04/10 for a Percutaneous Endoscopic Gastrostomy placement. The form, titled, Consent Process, reads, " ...The identity of the Patient's Personal Representative has been verified by---- (drivers license, other picture identification, court order, etc.) and that as ----- (parent, legal guardian etc.) such Personal Representative is legally authorized to sign this consent on behalf of the patient. Patient unable to consent because: Patient cannot communicate his/her decision concerning proposed care in an unambiguous manner." The section with "Physician One" signature was blank. The section for "Physician Two "s signature (if unable to to consent)" was blank. The findings were confirmed in an interview with the Chief Quality Officer on 06/23/10 at 1500.

Review of facility policy and procedure, titled, Consent for Operations and Other Procedures, reads, "...Procedure: A. Signature of surgeon....G. If a patient is unable to consent, two physicians, each of whom has examined the patient, must certify the patient's inability to consent, and complete documentation to support this...".

On the days of the Recertification survey based on observations, record reviews, and interviews, the hospital failed to ensure that food and dietetic service requirements were met in that the hospital provided no oversight of the dietetic system via an internal Quality Assurance and Process Improvement (QAPI) or an Infection Control program, failed to monitor the hospital's system for initiating patient referrals for nutrition consults through it screening process, failed to monitor the effectiveness of its dietary consult program, and failed to establish hospital policies and procedures for the dietary and dietetic programs. The Hospital failed to ensure that the contracted dietician provided supervision for the nutritional aspects of patient care and was available to consult and submit a timely report that could be utilized by other health care providers for 1 of 1 hospitalized patient (Patient #14), and by not providing ongoing nutritional assessments to ensure that appropriate interventions are made in response to the nutritional need of 3 of 3 swing bed residents.

The findings are:


On 06/22/10 at 0900, a review of hospital data for the Dietary Condition of Participation revealed a service agreement between the hospital and a dietary clinical service group dated July 30, 2009, that reads, "...1. General Obligations of .... 1.1. Services. ..... agrees to provide a dietician and Quality of Life Services to Medical Center on an as-needed basis, in accordance with any applicable requirements of federal, state and local laws and rules and regulations..". Review of hospital records and other data review on 06/24/10 at 0900 revealed a hospital form, titled, Dietician Consultant that read, '...Job Description: Provides clinical nutritional assessment and recommendations of care for patients in .... Hospital on an as needed basis based on the nurse's screening assessment and referral or physician order....".

On 06/21/10 at 1330, the Dietary Manager and Corporate Dietary Manager revealed that the dietician works at the hospital one (1) day a month on referral only. The Corporate Dietary Manager reported that the Dietician would not be able to come to the Hospital until the end of the week for an interview, and the Dietician could not be reached by telephone for an interview because the Dietician was in an area of poor telephone reception. The Dietary Manager reported that the back up to the Dietician was also unavailable for interview. The Dietary Manager reported that the Dietician had only been consulted on one patient in the hospital since the Dietician's services were contracted in July 2009. (Patient #14) As far as the Dietician's qualifications, the hospital submitted a current license only.

On 06/22/10 at 1230, observation of the distribution of patient lunch trays from the kitchen which was located in another facility (Skilled Nursing Facility) adjacent to the hospital revealed that the patient trays were delivered and transported from that building in an uncovered open cart. On 6/22/10 at 1245, Registered Nurse (RN) #11 verified the delivery cart containing the patient lunch trays was uncovered. RN #11 reported that he/she was not aware of any hospital guidelines related to dietary tray transport. RN #11 was unable to locate any hospital policies and procedures regarding food services.

On 06/24/10 at 1100, a review of a hospital form, titled, Inpatient Report/ Question Analysis that had a received date of 01/01/10 - 01/31/10 that read, "...Temperature of the food = 62.5, Quality of food = 67.5, Courtesy of person served food = 85. There were no benchmarks indicated to determine if the quality and temperature of the food was meeting patient expectations or any supporting evidence that the hospital had assessed, implemented any actions to address the issues identified by patients on the form, or any effort to evaluate the identified issues through the hospital's Quality Assurance and Process Improvement (QAPI) program or infection control program.

On 06/24/10 at 0830, the Chief Quality Officer revealed that the hospital had no policies and procedures or protocols for dietary services or for contacting the dietician for patient referrals. The Chief Quality Officer verified that there was no Quality Assessment Process Improvement or Infection Control oversight for its dietary services. The Chief Quality Officer verified that the hospital has had some problems because the dietician had not been seeing patients. The Chief Quality Officer reported that the delivery of dietary services in the hospital was fragmented and confirmed that only 1 hospitalized inpatient had received a dietary consult since July 2009.

On 06/22/10, a review of of hospital records and other data revealed the hospital had no policies and procedures related to patient nutritional assessment guidelines. The finding was confirmed with Registered Nurse #14 on 06/22/10 at 1200. On 06/23/10 at 1400, review of hospital records showed a hospital form, titled, Skin Assessment Protocol, dated 07/19/96, reviewed 05/23/01 that read, "..5. Patients with a Stage ll or greater should have a consult initiated with the Physical Therapist (must obtain physician order) and Dietary...". On 06/24/10 at 0950, the Chief Quality Officer revealed that the wound classification was deleted as a guideline for acquiring a dietary consult, but the hospital had no revised or new policies for nutritional consults for patients.

On the days of the Recertification Survey based on interview and facility record review, the Hospital failed to ensure that the contracted dietician was available to supervise the nutritional aspects of patient care for the hospital and for 1 of 1 hospitalized patient (Patient #14) who had received a dietary consult and for 3 of 3 swing bed admissions who never received a dietary consult. (Resident #1, #2, and #3)


The findings are:


On 06/22/10 at 0900, a review of hospital data revealed a service agreement between the hospital and a dietary clinical services group, dated July 30, 2009, that read, ".... 1. General Obligations of .... 1.1. Services. .... agrees to provide a dietician and Quality of Life Services to Medical Center on an as-needed basis, in accordance with any applicable requirements of federal, state and local laws and rules and regulations..". Review of hospital records and other written data on 06/24/10 at 0900 revealed a hospital form, titled, Dietician Consultant .... Hospital, that read, '...Job Description: Provides clinical nutrition assessment and recommendations of care for patients in .... Hospital on an as needed based on the nurse screening and assessment of patients or physician order....".

On 06/21/10 at 1330, the Dietary Manager and Corporate Dietary Manager revealed that the Dietician works at the hospital one (1) day a month on referral only. The Corporate Dietary Manager reported that the Dietician would not be able to come to the Hospital until the end of the week for an interview, and the Dietician could not be reached by telephone for an interview because the Dietician was in an area of poor telephone reception. The Dietary Manager reported that the back up Dietician was also unavailable for interview. The Dietary Manager reported that the Dietician had only been consulted on one inpatient in the hospital since the Dietician was contracted in July 2009. (Patient #14) As far as the Dietician's qualifications, the hospital submitted a current license only. Although the current hospital policy for swing bed patients required the dietician to consult on all swing bed patients, there was no evidence that the Dietician saw any swing bed patients on referral for nutritional consultation.

On 06/23/10 at 1430, a review of Patient #14's, (identified by hospital as the one hospitalized patient who had received a dietary consult via telephone and EMAIL) clinical record revealed the patient was admitted on 01/08/10 with a diagnoses of Atrial Fibulation with Rapid Ventricular Response and Diabetes Mellitus uncontrolled. Review of the patient's initial nutritional screen showed a score of more than 6 identifying the patient as high risk for nutritional deficits. On 01/10/10, the physician ordered a dietary consult for malnutrition. Review of the patient's record showed a form, titled, Registered Dietician E-Fax Recommendations Form, which read, "Date 1/10/10 with the patient's diagnoses, diet order, height, medications, labs, and a notation about the patient's pressure ulcers..". This current patient clinical information for Patient #14 was documented on the form by the Registered Nurse. The recommendation form for a dietary consultation continued to read, "...E-mailed completed form to Registered Dietician (RD)." The referral form, read, in the section to be used by RD, "will return via e-mail) with RD Recommendations. On 01/11/10, a second referral form was faxed to the RD by another nurse based on the original physician's order dated 1/10/10.
On 1/12/10 at 1420, the nurse recorded in the patient's chart ".... Nutrition: Spoke with the patient at bedside regarding by mouth (po) intake...Will call nutrition consultant for follow up."
On 1/12/10 at 1455, the nurse documented "Spoke with Nutrition consultant via phone. Informed of patient poor po intake, Albumin at 1.9, blood Urea Nitrogen (BUN) at 44. Physician contemplating PEG (Percutaneous Endoscopic Gastrostomy) placement. Stated he/she would be faxing over his/her recommendations soon." The patient's chart had the nutritional consult dated 1/12/10 at 6:36 P.M. sent to the hospital by EMAIL that read, "Attached is the consult. Let me know if they decide on a PEG and I will recommend the amounts and flushes. Thanks." Review of the nutrition consult dated 1/12/10 at 6:36 P.M. showed the Dietician recorded the patient's estimated nutritional needs as 1625 - 1950 K. (kilo) calories; EPN (Estimated protein Needs) 65 gm (grams) - 98 gms protein and 1950 - 2275 ml. (milliliters) of fluids. The Dietician recorded,".... is "hardly eating anything" according to the nurses. He/she is also not liking or drinking the Ensure. Patient is currently on IV (intravenous) antibiotics and an [sic] saline IV to help hydrate patient. The Dietician's recommendations read, "1. Liberalizing the diet to a Regular - NCS (no concentrated sweet diet); 2. Since patient does not seem to like sweets - try buttermilk or regular whole milk, and fruit juices; 3. Patient really needs a vitamin but until patient is able to consume food, it may upset the stomach; and 4. Patient may be a candidate for a PEG if physician and family agree. Glucerna 1.2 or 1.5 could be given through the tube to provide adequate nourishment. (RD can assist with further recommendations if done)". On 1/12/10 at 0930 A.M., the physician order, read, "5. Transfer to a swing bed." There was no documentation in the patient's chart that the physician saw the Dieticians's recommendations or ordered any changes. There was no evidence that the patient's intake and output was monitored although the patient had been identified to have little food intake and was receiving an Intravenous fluid infusion. There was no evidence that the patient's protein needs were monitored for changes in the consult. There was no evidence that the dietician conducted any follow up in the hospital to identify if recommendations were sufficient to meet the patient's needs.











21307

On 6/21/10 at 1430, review of swing bed Resident #1's open medical record revealed a sixty-year old admitted with diagnoses of Dementia, Peri-Rectal Abscess and Dehydration. The patient's admission assessment, dated 3/26/10, showed staff documented a nutritional risk score of "2 (two)-Good and was on a therapeutic diet. The patient's admission assessment also showed staff noted that the patient was at risk for skin breakdown and had poor skin integrity. The "Patient Progress Notes", dated 3/26/10 at 2132, showed staff documented that the resident had bilateral heel and left buttock ulcers. "Patient Progress Notes", dated 3/26/10 at 2114, showed staff documented that the patient ate 25%-50% of most meals. Progress notes, dated 3/27/10, showed staff documented a Stage 3 ulcer with serous drainage. The resident's dietary intake was 25% or less of most meals. Progress notes on 3/28/10 showed staff documented a Stage 2 ulcer to both ankles, approximately the size of a quarter. There was no documentation that a dietary consult was requested or completed.

On 6/22/10 at 1040, review Resident #2's closed medical record revealed a sixty-two year old admitted on 4/14/10 as a swing bed resident. Diagnoses included bilateral lower extremity Cellulitis, Diabetes Mellitus Type II, Hypertension, morbid Obesity, and Chronic Obstructive Pulmonary Disease. There was no documentation that a dietary consult was requested or completed.

On 6/22/10 at 1330, review of Resident #3's closed medical record revealed a seventy-seven year old admitted with diagnoses of Dehydration. There was no documentation in the record that a dietary consult was requested or completed. On 6/24/10 at 0945, the findings was reviewed with the Swing Bed Coordinator.

Review of Hospital Policy #HW1.16, "Plan for the Provision of Patient/Resident Care", revised 10/14/03, read, " ...VI. Roles of Patient/Resident Care Providers: ... 6. Dietary Manager/Dietician- A. Provides an assessment for all residents admitted to Swing Bed and the Nursing Center ... " .

On the days of the recertification survey based on record reviews and interviews, the hospital failed to ensure that patient nutritional needs were met in accordance with recognized dietary practices for 2 of 5 concurrent patient records reviewed (Resident #1 and Patient #13) and for 4 of 4 closed patient records reviewed where needed services was or was not identified and the patients did not receive the services. (Resident #2 and #3 and Patient #14)

The findings are:

On 06/23/10 at 1430, a review of Patient #14's, (identified by hospital as the one hospitalized patient who had received a dietary consult via telephone and EMAIL) clinical record revealed the patient was admitted on 01/08/10 with a diagnoses of Atrial Fibulation with Rapid Ventricular Response and Diabetes Mellitus uncontrolled. Review of the patient's initial nutritional screen showed a score of more than 6 identifying the patient as high risk for nutritional deficits. On 01/10/10, the physician ordered a dietary consult for malnutrition. Review of the patient's record showed a form, titled, Registered Dietician E-Fax Recommendations Form, which read, "Date 1/10/10 with the patient's diagnoses, diet order, height, medications, labs, and a notation about the patient's pressure ulcers..". This current patient clinical information for Patient #14 was documented on the form by the Registered Nurse. The recommendation form for a dietary consultation continued to read, "...E-mailed completed form to Registered Dietician (RD)." The referral form, read, in the section to be used by RD, "will return via e-mail) with RD Recommendations. On 01/11/10, a second referral form was faxed to the RD by another nurse based on the original physician's order dated 1/10/10.
On 1/12/10 at 1420, the nurse recorded in the patient's chart ".... Nutrition: Spoke with the patient at bedside regarding by mouth (po) intake...Will call nutrition consultant for follow up."
On 1/12/10 at 1455, the nurse documented "Spoke with Nutrition consultant via phone. Informed of patient poor po intake, Albumin at 1.9, blood Urea Nitrogen (BUN) at 44. Physician contemplating PEG (Percutaneous Endoscopic Gastrostomy) placement. Stated he/she would be faxing over his/her recommendations soon." The patient's chart had the nutritional consult dated 1/12/10 at 6:36 P.M. sent to the hospital by EMAIL that read, "Attached is the consult. Let me know if they decide on a PEG and I will recommend the amounts and flushes. Thanks." Review of the nutrition consult dated 1/12/10 at 6:36 P.M. showed the Dietician recorded the patient's estimated nutritional needs as 1625 - 1950 K. (kilo) calories; EPN (Estimated protein Needs) 65 gm (grams) - 98 gms protein and 1950 - 2275 ml. (milliliters) of fluids. The Dietician recorded,".... is "hardly eating anything" according to the nurses. He/she is also not liking or drinking the Ensure. Patient is currently on IV (intravenous) antibiotics and an [sic] saline IV to help hydrate patient. The Dietician's recommendations read, "1. Liberalizing the diet to a Regular - NCS (no concentrated sweet diet); 2. Since patient does not seem to like sweets - try buttermilk or regular whole milk, and fruit juices; 3. Patient really needs a vitamin but until patient is able to consume food, it may upset the stomach; and 4. Patient may be a candidate for a PEG if physician and family agree. Glucerna 1.2 or 1.5 could be given through the tube to provide adequate nourishment. (RD can assist with further recommendations if done)". On 1/12/10 at 0930 A.M., the physician order, read, "5. Transfer to a swing bed." There was no documentation in the patient's chart that the physician saw the Dieticians's recommendations or ordered any changes. There was no evidence that the patient's intake and output was monitored although the patient had been identified to have little food intake and was receiving an Intravenous fluid infusion. There was no evidence that the patient's protein needs were monitored for changes in the consult. There was no evidence that the dietician conducted any follow up in the hospital to identify if recommendations were sufficient to meet the patient's needs.

On 06/22/10 at 1400, clinical record review of Patient #13 who was admitted on 06/20/10 with a diagnosis of Urinary Tract Infection not otherwise specified(NOS) showed the hospital form, titled, Initial Interview, dated 06/20/10, reads, " .... a weight of 130 lbs (pounds), previous hospitalization for failure to thrive, patient dependent, total care needed for activities of daily living, is oriented to person, follows simple commands only. Injury Risk Assessment showed the patient was disoriented at all times, and the patient's nutritional status showed "eats/drinks 50% or less of each meal...". On the nutritional screen assessment, the nurse documented the patient had no difficulty in feeding self which gave the patient a 0 score, bringing the total score of the nutritional score to 3-5 requiring the intervention to reassess in 2 weeks/ or as needed (prn), Since the nurse recorded inaccurate information instead of the data obtained on the patient's initial assessment, the patient's nutritional score was lower than it would have been with the accurate assessment data. After adding the additional 2 points for the patient's inability to feed self, the patient's nutritional score would have been 6 - 8 which would have required additional nutritional interventions for the patient. The patient's clinical record showed a hospital form, titled, Problem Activity, dated 06/20/10, which read, ".... size of the wound: 3 Stage 2 areas noted to coccyx area. 1 was 1/2 x 1/2 centimeter (cm). 2nd area was 1 cm x 1 cm and 3rd area was 1 cm x 2 cm...". Clinical Record review of hospital form, titled, Graphic and Intake/Output showed the Patient Diet and Percent Consumed was blank.

On 6/21/10 at 1430, review of swing bed Resident #1's open medical record revealed a sixty-year old admitted with diagnoses of Dementia, Peri-Rectal Abscess and Dehydration. The patient's admission assessment, dated 3/26/10, showed staff documented a nutritional risk score of "2 (two)-Good - and the patient was on a therapeutic diet. Staff documented that the patient was at risk for skin breakdown and had poor skin integrity. The "Patient Progress Notes", dated 3/26/10 at 2132, showed staff documented that the resident had bilateral heel and left buttock ulcers. "Patient Progress Notes", dated 3/26/10 at 2114, showed staff documented that the patient ate 25%-50% of most meals. Progress notes, dated 3/27/10, showed staff documented a Stage 3 ulcer with serous drainage. The resident's dietary intake was documented as 25% or less of most meals. Progress notes on 3/28/10 showed staff documented a Stage 2 ulcer to both ankles, approximately the size of a quarter. There was no documentation that a dietary consult was requested, completed, or that the patient's nutritional status was assessed and monitored in order to assure the patient was receiving the appropriate care and services.

On 6/22/10 at 1040, a review Resident #2's closed medical record revealed the sixty-two year old was admitted on 4/14/10 as a swing bed resident. Diagnoses included bilateral lower extremity Cellulitis, Diabetes Mellitus type II, Hypertension, morbid Obesity, and Chronic Obstructive Pulmonary Disease. There was no documentation that a dietary consult was requested or completed. There was no evidence that the patient's diet was appropriate to meet the patient's nutritional needs. There was no documentation that the patient's nutritional status was monitored.

On 6/22/10 at 1330, review of Resident #3's closed medical record revealed a seventy-seven year old admitted with diagnoses of Dehydration. There was no documentation in the record that a dietary consult was requested or completed. On 6/24/10 at 0945, the findings was reviewed with the Swing Bed Coordinator.

On the days of the Recertification Survey based on observation and interview, the Hospital failed to have a current therapeutic diet manual that was available to the medical and nursing staff that was approved by the dietician and medical staff.

The findings are:

Observation of the Medical Surgical Unit on 06/22/10 at 0900 showed there was no therapeutic diet manual. Registered Nurse #11 verified the finding on 06/22/10 at 1430. The Senior Clinical Director confirmed that the hospital does not have a current therapeutic diet manual approved by the dietician and medical staff.

On the days of the Recertification Survey based on observation and interview, the facility failed to ensure a safe sanitary environment was maintained to assure patient safety. Observations of the hospital revealed peeling paint in the tub room, peeling paint and holes in walls in patient rooms, cracked flooring, and dirty ice machine in the Post Anesthesia Care Unit (PACU)/Dialysis hallway and in the medical records area.

The findings are:

On 06/23/10 at 1000, during a tour of the facility with the Same Day Surgery (SDS) Manager, observations revealed a dust and grayish material was present on the ice machine in the PACU area, peeling paint and holes in the walls of the PACU, and floors with cracks in the SDS. The findings were verified by the SDS Manager during the rounds.



27175

On 6/21/10 at 1245, during a facility tour with the Senior Clinical Director, observations revealed paint peeling on the pipes above the tub and rust surrounding the drain in all three tub rooms within the facility. In the maintenance area of the facility, observation showed several browned and warped ceiling tiles were noted. During a tour of the medical records areas on 6/23/10 at 0930 in the main medical records office an area of brown warped ceiling tiles were observed adjacent to the air conditioning unit. In a medical records storage area near the physicians lounge, an area of brown warped ceiling tiles were observed adjacent to the air conditioning unit, and the carpet beneath the air conditioning unit was water stained. The findings were verified by the Director of Health Information Management on 6/23/10 at 1030.

On the days of the Recertification Survey based on observation, interview, and record review, the Hospital failed to ensure that patient care equipment was available and in good working order(Ambu bag, pediatric airways), and the facility did not impose hazards to patients and staff (water on floor in Radiology Record Room, stained ceiling tiles in hallway medical record room) and a door propped open with a wheel chair leg. (dictation room)


The findings are:

On 06/21/10 at 1235/ observation of the Code Cart located on the Medical Surgical floor revealed only a #1 toddler size oral airway. Observation of the crash cart located in the Dictation Room revealed a pediatric Ambu bag that was flat and could not be inflated properly. The findings were confirmed with Registered Nurse (RN) #16. On 06/21/10 at 1300, facility record review, titled, Respiratory Drawer List, reads, "...Bag of Pediatric/Infant Oral Airways (various sizes)...".
On 06/24/10 at 0900, a tour of the Radiology Medical Record Room revealed a large amount of standing water on the floor near the entrance. The finding was confirmed with Radiology Technician #1. On 06/24/10 at 1235, observation of the hallway door of the Dictation Room revealed that the door was propped open using a leg from a wheelchair. The finding was confirmed with RN #16.



27175

During a tour of the medical records areas on 6/23/10 at 0930 in the main medical records office, observations showed an area of brown warped ceiling tiles adjacent to the air conditioning unit. In a medical records storage area near the physician lounge, observation showed an area of brown warped ceiling tiles adjacent to the air conditioning unit, and the carpet beneath the air conditioning unit was water stained. The findings were verified by the Director of Health Information Management on 6/23/10 at 1030.

On the days of the Recertification Survey based on observation and interview, the facility failed to provide a safe environment which was maintained to assure an environment free of infections for 4 of 4 dialysis machines that had no evidence of the culture reports for April 2010 and May 2010,for inappropriate distribution of patient food trays, and for expired culture tubes in the Radiology Department.

The findings are:

On 6/21/2010 at 1330, a review of the Dialysis Station Machine records revealed no documentation that four (4) of 4 dialysis machines in the Dialysis Unit had cultures collected and that the results were reviewed to assure the machine cultures were within the normal range during April 2010 and May 2010. There was no documentation that the RO (Reverse Osmosis) system was disinfected with Renalin during May 2010. There was no documentation that the Medical Director or Nurse Manager reviewed the culture reports for April 2010 and May 2010 or the RO Loop disinfection report for May 2010. The findings were verified by the Dialysis Nurse Manager on 6/21/10 at 1330 who reported that a copy of the cultures reports should have been obtained and the results reviewed. On 6/23/2010 at 1115, during a random observation in the Emergency Department, a sterilized wrapped instrument was found with an expiration date of 4/02/2001. The finding was verified by the Emergency Department Nurse Manager on 6/23/10 at 1117.



27544

On 06/22/10 at 1230, observation of the distribution of the lunch trays revealed all of the patient lunch trays were transported on an uncovered cart from the kitchen located in the nursing home adjacent to the hospital. Registered Nurse (RN) #11 confirmed the finding on 06/22/10 at 1245.

On 06/22/10 at 1415, observation of the Crash Cart in the Computed Axial Tomography (CAT) scan Room revealed a lot of #4 culture tubes with an expired date of 10/23/09 and a lot #8 culture tubes with an expired date of 03/18/10. The Radiology Director explained that he/she was unsure why the culture tubes were on the cart.

On the days of the Recertification Survey based on interview and record review, the hospital failed to educate patient care staff regarding organ donation issues for 2 of 2 Registered Nurses whose personnel files were reviewed. (Registered Nurse #11 and #16)

The findings are:

On 06/23/10 at 1400, review of the personnel records of Registered Nurses #11 and #16 failed to show any orientation or continuing training related to organ donation. On 06/24/10 at 0915, the Senior Clinical Director revealed that the hospital does not offer training to nursing staff related to organ donation in orientation or in annual training.

On the days of the Recertification Survey based on interview and review of hospital policies and procedures, the facility failed to assure high standards of practice and patient care were maintained by lack of implementation and enforcement of Surgical Services Policies and Procedures for the central sterile processing area for "leak testing GI (Gastrointestinal) Fiberoptic Scopes in the operating room.

The findings are:

On 06/22/10 at 1045, during a tour of the Central Sterile Department, an interview with the Central Sterile Technician (CST) revealed that the CST was not aware of the hospital policy on leak testing for all immersible fiberoptic scopes or the requirement to document the results of the biological testing of the sterilizer.
Hospital policy, titled, Leak Testing - G.I. Fiberoptic Scopes, which states, "A leak test will be performed prior to each use on all immersible fiberoptic endoscopes, and personnel to maintain documentation of results from daily biological testing of the sterilizer."

On the day of the Recertification Survey based on record review and staff interview, the facility failed to ensure that the Nurse Manager of the Emergency Department (ED) had a current certification in Advanced Cardiac Life Support (ACLS) required per hospital policy to meet the written emergency procedures and anticipated needs of the hospital's Emergency Department.

The findings are:

On 6/22/2010 at 1050, the ED Nurse Manager reported that some of the ED staff did not have their ACLS certification required by hospital policy but the Nurse Manager reported that he/she did not know which staff were not current. Review of hospital training records revealed that the ED Nurse Manager's ACLS certification had expired in November 2008. The findings were verified on 6/23/2010 by the Chief Quality Officer.

Hospital Job Description, signed by the Emergency Department Nurse Manager, reads, "... Qualifications: 1. Licensure, Certification: a. Licensed to practice as a Registered Nurse in the State of South Carolina. b. Current Basic Life Support. c. Current Advanced Cardiac Life Support ... " .

On the days of the Recertification Survey based on observation, interview, and facility record review, the Hospital failed to incorporate the effectiveness and delivery of its dietary services into its Quality Assessment and Performance Improvement(QAPI) program to ensure utilization of consults with dietician in that the hospital in that the hospital had only one dietary consult for one patient via fax and EMAIL since July 2009, and to improve delivery of dietetic services.

The findings are:

On 06/24/10 at 0830, the Chief Quality Officer revealed that the hospital had no protocols or policies and procedures for making referrals to the hospital's contract dietician. The Chief Quality Officer reported that the hospital had no policies and procedures for dietary services, and the hospital had no oversight or monitoring of its dietary services through infection control or its Quality Assurance Process Improvement program that also included monitoring for utilization of dietician consults through patient referrals. The Chief Quality Officer verified the delivery of dietary services was very fragmented presently.

On the days of the Recertification Survey based on interview and facility record review, the Hospital failed to assess, identify, implement a plan or monitor data collected from patient satisfaction surveys to identify opportunities for improvement in it delivery of dietary services, or to collect any other data related to dietary services.

The findings are:

On 06/24/10 at 1100, a review of facility written materials, specifically a hospital form, titled, Inpatient Report, Question Analysis that was received 01/01/10 - 01/31/10, that read, "...Temperature of the food = 62.5, Quality of food = 67.5, Courtesy of person who served of food = 85. The hospital had no predetermined benchmarks to determine if the quality and temperature of the food served to its patient population was meeting or declining expectations of customers or any supporting evidence that actions were taken to bring about improvements. On 06/24/10 at 0830, the Chief Quality Officer verified that there were some indicators related to the delivery of dietary services in the patient satisfaction survey. The hospital had no oversight or monitoring its dietary services through infection control or its Quality Assurance Process Improvement program for dietary services that also included monitoring for utilization of dietician consults through patient referrals. The Chief Quality Officer verified the delivery of dietary services was very fragmented presently. .

On the days of the Recertification survey based on interview and record review, the hospital failed to ensure that its dietary services were monitored to ensure that patient trays were delivered in a safe manner, and that patient satisfaction issues were assessed and monitored through an effective Quality Assurance and Process Improvement (QAPI) program to ensure the quality of its food and nutrition.

The findings are:

On 06/24/10 at 1100, a review of a facility form, titled, Inpatient Report/ Question Analysis-with a Received date of 01/01/10 - 01/31/10, read, "...Temperature of the food = -62.5, Quality of food =67.5, Courtesy of person served of food = 85. There were no benchmarks to determine if the quality and temperature of the food was meeting patient expectations or any supporting evidence that the hospital had assessed, implemented any actions to address the issues, or evaluate the patient issues with dietary services.

On 06/22/10 at 1230, observation of the distribution of the patient lunch trays from the kitchen located in another facility revealed that the patient trays were delivered and transported from a building (facility) adjacent to the hospital in an uncovered open cart. On 6/22/10 at 1245, Registered Nurse (RN) #11 verified the delivery cart was uncovered. RN #11 reported that he/she was not aware of any guidelines related to dietary tray transport. RN #11 was unable to locate any hospital policies and procedures regarding food services.

On 06/21/10 at 1310, an interview was conducted with Patient #12 who was admitted on 06/18/10 with a diagnosis of Anxiety. The family member reported that the patient's breakfast that morning had consisted of eggs and cheese that looked burnt and stuck to the plate. The family member reported that the kitchen served the same thing for every meal.

On 06/21/10, Registered Nurse #1 reported that when patients have a complaint about food, the complaint can be remedied by the nurse going over to the building where the dietary services are located and getting another tray for the patient. RN #1 verified that staff have had to leave the nursing unit to go to the other building to retrieve the patient another tray but could not quantify how often it happens. The hospital had no dietary manual available on the nursing units.

Cross Reference to A 0630: The hospital failed to ensure that patient nutritional needs were met in accordance with recognized dietary practices for 2 of 5 concurrent patient records reviewed (Resident #1 and Patient #14) and for 2 of 2 closed bed patient records reviewed where needed services was identified but the patients did not receive the services. (Resident #2 and #3)

On the days of the Re-certification survey based on interview, record review, and review of hospital policy and procedure, the hospital failed to ensure that the swing bed activities's program included resident participation for one of one open swing bed records reviewed for care and services. (Resident #1)

The findings are:

On 6/21/10 at 1430, a review of Resident #1's open medical record revealed the sixty-year old was admitted with diagnoses of Dementia, Peri-rectal Abscess and Dehydration. Review of the "Individual Participation Record", a check-off sheet of activities, for the months of May 2010 and June 2010 showed staff documented resident participation in several activities. Review of the weekly progress notes for 5/3/10, 5/10/10, 5/17/10 showed staff documented that the resident participated in activities of choice but did not include the outcomes/response of the resident. The "Individual Participation Record" also included a line on the form for participation in "TV/Radio/Music". It was unclear as to which activity the resident participated in. Watching television is not an activity.

On 6/22/10 at 1040, a review Resident #2's closed medical record revealed the sixty-two year old was admitted on 4/14/10 as a swing bed resident. Diagnoses included bilateral lower extremity Cellulitis, Diabetes Mellitus Type II, Hypertension, morbid Obesity, and Chronic Obstructive Pulmonary Disease. Review of the "Individual Participation Record", a check-off sheet of activities for the month of April 2010, showed staff documented resident participation in several activities. Review of the two progress notes entered in the patient's record and dated 4/14/10 and 4/19/10 did not include documentation of outcome/response of the resident related to the activities that the resident participated in. The "Individual Participation Record" also included a line on the form for participation in "TV/Radio/Music". It was unclear as to which activity resident participated in. Watching television is not an activity. On 6/24/10 at 0945, the findings were verified with the Activities Director.

Review of Hospital Policy #HW1.16, "Plan for the Provision of Patient/Resident Care", revised 10/14/03, read, " ... 8. Activities Coordinator ... C. Conducts activities to determine the resident's satisfaction with the care being provided... ".