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On the days of the recertification survey based on observations and interview, 2 of 6 Registered Nurses(RN 1 and RN 2) failed to ensure the patient's privacy was maintained during medication administration via feeding tubes for 2 of 3 patients observed for care and services. (Patient 5 and 7)

The findings include:

On 02/11/2014 at 8:55 a.m., observation showed Registered Nurse 1 failed to close Patient 7's door during medication administration via the patient's feeding tube. On 02/11/2014 at 9:40 a.m., the finding was verified with RN 1. On 02/11/2014 at 9:40 a.m., observation showed RN 2 failed to close Patient 5's door during medication administration via the patient's feeding tube. On 02/11/2014 at 10:10 a.m., the finding was verified with RN 2.

On the days of the hospital survey based on concurrent patient record review and review of hospital policy and procedure, the hospital failed to provide every two hour documentation of interventions offered to patients while on restraints for 2 of 2 patient records reviewed for restraints. (Patient 18 and 19).

The findings are:

On 02/18/14 at 2:15 p.m., concurrent record review for Patient 18 revealed the patient was admitted to the hospital on 01/24/14 with physician orders for restraints during the current hospitalization. Review of the hospital's 24 hour restraint record form revealed the intervention section required every 2 hour documentation for assessments of "food/fluid offered, toileting/bedpan, skin check, circulation check, restraint removed/ROM (range of motion), comfort measures and other". Further review of the hospital's 24 hour restraint record form for Patient 18 revealed there was no every 2 hour documentation completed for the patient when on restraints: 01/27/14, 01/28/14, 01/29/14, 02/05/14, 02/10/14, 02/11/14, and 02/13/14.

On 02/18/14 at 3:00 p.m., closed record review for Patient 19 revealed the patient was admitted to the hospital on 10/08/13 with physician's orders for restraints during the patient's hospitalization. Review of the hospital's 24 hour restraint record form revealed the intervention section for required every 2 hour documentation for "food/fluid offered, toileting/bedpan, skin check, circulation check, restraint removed/ROM (range of motion), comfort measures and other" was incomplete. Further review of the hospital's 24 hour restraint record form revealed there was no required every 2 hour documentation of interventions on 01/03/14, 01/04/14, 02/03/14, 02/05/14, 02/06/14 and 02/09/14 when the patient was restrained.

Hospital policy, titled, "Restraint Interventions,....g. Interventions....Patient must be monitored every 2 hours for any changes in condition and the following must be provided: Fluids and food every 2 hours, Toileting/bedpan every 2 hours, hygiene care at least every 24 hours, Remove restraints, perform ROM (range of motion), check skin condition and circulation every 2 hours, Measure vital signs per MD (medical doctor) order, Check comfort related to body temperature, modesty, and visibility to others every 2 hours....".

On the days of the hospital survey based on interview and review of the hospitals Quality Assessment Performance Improvement (QAPI) data, the hospital failed to provide oversight for infection control for staff of its contracted services in the hospital's Quality program.

The findings are:

On 02/18/14 at 3:15 p.m., review of the hospital wide QAPI program revealed the hospital had no evidence of its oversight/training/monitoring of infection control practices of its contracted staff services in patient care areas. On 02/18/14 at 10:30 a.m., during an interview with the Infection Control Officer, he/she revealed that no infection control training and/or monitoring has been provided to contracted staff providing services in patient care areas for the hospital. The Infection Control Officer reported that he/she was unaware if staff provided under contractural services received any infection control training and/or monitoring.

On the days of the recertification survey based on observations, interview, and review of hospital policies and procedures, the hospital failed to ensure 1 of 1 Registered Nurses(RN 2) followed its own procedures for checking gastric residuals for 1 of 3 patients with feeding tubes. (Patient 5 )

The findings include:

On 02/11/2014 at 9:40 a.m., observation of RN 2 revealed Registered Nurse (RN) 2 used a syringe with a plunger to check for the residual amount of tube feeding in the patient's stomach and placement of the feeding tube before administering Patient 5's medication via the feeding tube. RN 2 aspirated the gastric contents and then emptied the aspirated stomach contents into the trash can instead of re - instilling the residual contents back into the stomach. RN 2 aspirated the stomach gastric contents several times via the patient's feeding tube and emptied all of the gastric contents into the trash. On 02/11/2014 at 10:10 a.m., the finding was verified with RN 2

Hospital policy and procedure, tilted, "...Lippincott's Nursing Procedures FIFTH EDITION ... copyright 2009 by Lippincott Williams & Willkins", reads, "...Tube Feedings...Delivering a gastric feeding...To assess gastric emptying, aspirate and measure residual gastric contents. Hold feedings if residual volume is greater than the predetermined amount specified in the practitioner's order (usually 50 to 100 ml). Re - instill any aspirate obtained...".

On the days of the recertification survey based on concurrent and closed record reviews, interview, and review of hospital policy and procedures, the hospital failed to ensure its nursing staff develops and keeps current a nursing care plan for each patient with goals, interventions, and evaluation of presenting problems as well as new onset problems for 7 of 19 concurrent patient charts (Patient Corley, Patient Birchmore, and Patient Mozelle, 6, 8, 12, 13) and 4 of 11 closed charts. (2,4,5,6,)

The findings are:

On 2/18/2014 at 10:00 a.m., review of closed Patient 2's chart revealed the patient was admitted on 1/28/2014 at 9:33 a.m. Review of the patient's nurse care plan dated 1/29/2014 had only a discharge disposition problem identified. Review of the patient's plan of care revealed the nurse care plan had no problems or updates to address the presence of the feeding tube, how to take care of the patient's tracheostomy, or the aerosol treatments ordered for the patient. The patient also had a peripherally inserted central catheter (PICC) and care of the central catheter was not on the patient's plan of care.

On 2/18/2014 at 10:50 a.m., a review of Closed Patient 4's medical record revealed the patient was admitted on 2/06/2014 at 9:49 a.m. with a complex wound. There was no updates to the patient's plan of care even though documentation in the patient's chart showed the patient had a complex wound care system including a colostomy wafer to collect drainage from the fistula (an abnormal connection between an organ). There was no documentation of the fistula or the assessment of the wound or ordered wound care. On 2/18/2014 at 11:00 a.m., the Nursing Director confirmed that the patient's care plan had not been updated.

On 2/18/2014 at 11:00 a.m., review of Closed Patient 5's medial record revealed the patient was admitted on 1/22/2014 to wean the patient off the ventilator. Documentation in the patient's chart showed the patient had a feeding tube in place, required residual gastric checks every 4 hours, required turning every 2 hours, required suctioning of the airway, and a pulse oximetry to assess the patient's oxygenation level, and a PICC line. The patient's nurse plan of care addressed none of the problems identified. On 2/18/2014 at 11:15, the Nursing Director confirmed the finding.

On 2/18/2014 at 11:45 a.m., review of Closed Patient 6's medical record revealed the patient was admitted on 1/27/2014 at 12:02 a.m. with a diagnosis of wound care and Intravenous antibiotic therapy. Documentation showed the patient was admitted with a Foley catheter (tube in the bladder), PICC line, CPAP (continuous positive airway pressure), respiratory treatments, and oxygen therapy during the day. The patient's nurse plan of care addressed none of the issues identified in the patient's chart. On 2/18/2014 at 12:05 p.m., the Nursing Director verified the finding.

On 2/18/2014 at 2:20 p.m., review of concurrent Patient 12's medical record revealed the patient was admitted on 2/14/2014 at 11:49 a.m. with a diagnosis of respiratory failure. Documentation in the patient's chart showed the patient required wound care, colostomy care, hemodialysis, intravenous access with fluid administration, PICC line, mechanical ventilation, pulse oximetry (to check oxygen saturations), and blood glucose checks. The patient's nurse plan of care addressed none of the issues identified in the patient's chart. On 2/18/2014 at 2:40 p.m., the finding was verified with the Chief Nursing Officer.










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On 02/18/2014 at 2:10 p.m., review of concurrent Patient 6's chart revealed the patient was admitted on 11/22/2013. Review of the patient's nursing plan of care revealed nursing staff failed to identify the patient's feeding tube as a problem with goals and interventions for nutritional management. On 02/18/2014 at 4:10 p.m., the finding was verified with the Chief Nursing Officer.

On 02/18/2014 at 11:00 a.m., review of Patient 8's concurrent chart showed the patient was admitted on 02/09/2014. Review of the patient's nursing plan of care revealed nursing staff failed to identify the patient's PICC (central catheter inserted in a vein) line as a problem with goals and interventions for infection control prevention and management documented. On 02/18/2014 at 12:00 p.m., the finding was verified with the Chief Nursing Officer.

On 02/18/2014 at 3:30 p.m., review of Patient 13's concurrent chart showed the patient was admitted on 2/14/2014. Review of the patient's nursing care plan revealed nursing staff failed to identify the patient's feeding tube, tracheostomy, Foley catheter, or contact precautions as problems with goals and interventions for infection control and nutritional management documented. The only problem documented on the patient's nursing plan of care was "D/C Disposition" by the case manager. On 02/18/2014 at 4:10 p.m., the findings were verified with the Chief Nursing Officer.





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On 2/18/2014 at 10:00 a.m., review of Patient 11 's chart showed the patient was admitted on 2/7/2014 for acute respiratory failure status post Subarachnoid Hemorrhage. Patient was admitted with Methicillin Sensitive Staph Aureus(MRSA), Tracheostomy, Ventilator, PEG (Percutaneous Endoscopic Gastrostomy) tube for nutrition, Diabetes Mellitus, Hypertension, Hyperlipidemia, and Peripheral Arterial Disease. The patient's medication included but was not limited to Aspirin, Plavix, and Lovenox. The patient was on intake and output and had a Foley catheter. Review of Nurse Notes dated 2/10/14, 2/11/14, 2/12/14, 2/13/14, 2/14/14, 2/15/,14, 2/16/14, and 2/17/14 showed the patient was restrained with 4 side rails elevated and use of mittens. On 2/18/2014 at 10:15 a.m., review of the patient's nursing plan of care revealed one problem dated 2/11/2014 for Discharge Disposition by the Case Manager. On 2/14/2014, nursing staff documented a problem for potential for infection related to indwelling devices (Trach(Tracheostomy) to vent(ventilator), PI IC (Intravenous catheter) line, Foley catheter) and a problem for Confusion and pulling on medical devices). The "outcome section" for potential for infection and discharge disposition problems was blank. For the problem identified as Confusion, the nurse recorded in the outcome section, "2/14 Resident confused and restless @ (at) times and pulls on medical devices. SR (side rails) x (times) 4 to define parameters and mittens applied." Although the patient was admitted on 2/7/2014, the first problem identified was by Case Management but was not documented until 2/11/2014 which was four days after the patient's admission. Although the patient's chart clearly states that the patient had the devices on admission cited in the problem identified as "potential for infection", that problem was not documented until 2/14/2014 which was seven days after admission. There was no problem documented related to the patient's identified infection with MRSA, for alteration in nutrition (PEG), alteration in elimination pattern(Foley), or problem for anticoagulation medications(Plavix, Aspirin, Lovenox), or for use of restraints. The patient's care plan listed restraints only as the outcome for the problem documented as "confusion". Hospital staff failed to develop and update a nursing care plan for the patient that included the significant problems that the patient presented with. No significant patient problems were addressed until 2/14/2014 which was seven days after the patient's admission.

On 2/18/2014 at 11:30 a.m., review of Patient 9's chart revealed the patient was admitted on 2/6/2014 with Sacral Decubitus Ulcer, status post debridement with slow healing wound. Review of the patient's history and physical revealed the patient had T-10 paraplegia and neurogenic bowel and bladder after a thoracic kyphosis surgery in 2010 and 2013. After the last surgery, the patient was admitted to rehab and developed a decubitus ulcer which worsened in 2014 with subsequent fever and chills and was admitted to an acute hospital for continuing care to include surgical intervention and intravenous antibiotics. Patient 9 had a cholecystectomy with drain while an inpatient in the acute care hospital. Patient 9 was transferred to this hospital for negative pressure wound therapy, wound care, monitoring of gall bladder drain, depression, continuous antibiotic therapy, paraplegia, and management of multiple health issues to include nausea and vomiting. Review of the patient's nurse plan of care revealed that on 2/6/14, a discharge disposition problem was documented. None of the patient's other health issues were identified on the nurse care plan. On 2/11/14, a nurse documented "impaired skin integrity" but failed to include interventions related to the patient's bowel and bladder issues. The nurse also failed to document any outcomes in the outcome section for this problem. On 2/17 - 18, 2014, the nurse documented a problem for "infected sacral decubitus" and in the outcome section recorded 2/7 CRP elevated 115 prealbumin decreased 5.3 abt (antibiotics) continued". The patient's care plan failed to address issues with nutrition, bowel and bladder, mobility, and the patient's depression as well as other health issues that could impact on the patient's potential to reach maximum well being.

On 2/18/2014 at 12:00 p.m., review of Patient 10's chart revealed the patient was admitted on 2/17/2014 Osteomyelitis of the right arm. Review of the history and physical dated 2/8/14 showed the patient had Diabetes Mellitus, Hypertension, ETOH (Ethyl alcohol) abuse (30 year history), right arm pain, decreased appetite, weight loss, and a culture of the right arm tissue was positive for Methicillin Resistant Staph Aureus. Review of the patient's nurse care plan showed the Case Manager documented a discharge disposition problem dated 2/17/2014. The outcome section for the discharge disposition problem was blank. Nursing staff had identified no problems for nutrition, infection control, Hypoglycemia and Hypoglycemia, Delirium Tremens, mobility, or wound care. Nursing failed to initiate a care plan that included the patient's major nursing needs on admission.

On 2/18/2014 at 11:00 a.m., the Unit Manager reported that he/she was the only nurse on the floor that initiated and or updated all of the patients' care plans. She stated that the unit has a meeting once a week for updating the care plans. The Head Nurse stated that he/she does what he/she can get to.

On 2/18/2014 at 10:20 a.m., the Nursing Director stated that he/she is responsible to initiate all patient care plans and that updates were on a weekly basis only during the interdisciplinary group (IDG) meeting and were not reviewed on an ongoing basis.

Hospital policy, titled, "PATIENT PLAN OF CARE", revised 9/03, states "...The Registered Nurse (RN) is responsible for initiating an individualized plan of care for the patient, based upon findings of the admission database/assessment, observations, information obtained from the patient/family and other related sources of care. . An RN is to complete an assessment of the patient's needs, problems, capabilities and limitations within 24 hours of admission...The plan of care is evaluated and updated on a continuous basis by RNs and appropriate interdisciplinary staff...".

On the days of the hospital recertification survey based on interview, patient record review, and review of hospital policy and procedures, the hospital failed to have physician orders for leaving medications at the bedside for 1 of 1 observations of medication administration and no physician orders for dialysis treatments for Patient 19.


The findings are:


On 02/11/14 from 9:35 a.m. - 9:45 a.m., observations revealed a patient on contact precautions with physician orders for Flonase spray 2 sprays each nostril daily. Observations during medication administration revealed (1) bottle of Flonase spray and (1) albuterol inhaler pump labeled with the patient's name and other data on the bedside table. Review of patient's physician orders revealed there was no physician order for bedside medication. On 02/11/14 at 9:45 a.m., Registered Nurse 5 revealed, the "medication may have been left since the patient is on contact precautions but an order to do so is to be obtained from the physician".

On 02/10/14 at 1:45 p.m., concurrent chart review for Patient 19 revealed the patient was admitted to the hospital on 10/08/13. Review of dialysis treatment sheets revealed the patient received dialysis without physician orders on 01/03/14, 01/08/14, 01/10/14, 01/13/14, 01/14/14, 01/15/14, 01/17/14, 01/21/14, 01/25/14, 01/30/14, 02/01/14, 02/04/14, 02/06/14 and 02/08/14. On 02/10/14 at 2:30 p.m., the Acute Services Dialysis Director revealed "there is supposed to be a routine order written for those patients that we know are chronic dialysis patients or there is supposed to be a dialysis order sheet".

Hospital policy, titled, "FMS Inpatient Services Administrative Guidelines, FMS-CS-IS-I-500-040 A", reads, "....The FMS Inpatient Services or apheresis must be ordered by an appropriately credentialed physician. Orders must be appropriately communicated and written on the medical record prior to treatment....".

On the days of the hospital recertification survey based on observations, interview, and review of hospital policy and procedures, the hospital failed to ensure expired medications were removed from the hospital's Pyxis machine.

The findings are:

On 02/11/14 at 10:00 a.m., random observations of the Pyxis machine revealed (11) Prostat Sugar free advanced wound care (AWC) tubes expired 2/6/14, (3) Jantoven (warfarin sodium tablets) expired 11/13, and (15) Mucinex packages noted with no expiration dates. On 02/11/14 at 11:05 a.m., Pharmacy Technician 1 revealed annual updates are performed each year to check for expired medications as well as monthly updates. Pharmacy Technician 1 reported, "The Mucinex tablets come packaged whereby when I cut them a part, one of the packages has the lot number and the expiration date while the other tablet doesn't have anything on it".

Hospital policy, titled, "Medication Management/Storage, policy: MM-2.20-11", reads, "....Outdated or otherwise unusable drugs are identified, removed from stock, and stored to prevent their distribution and administration....".

On the days of the hospital survey based on observations, interview, and review of hospital dietary contract, the hospital failed to maintain acceptable dietary levels for food temperatures as noted on a test tray.

The findings are:

On 02/10/14 at 12:45 p.m., a sample dietary patient tray's food items were tested to ascertain the food temperatures of the food items on the tray when delivered to the nursing unit. The iceberg salad tested at 57.2 degrees Fahrenheit (F) which was 17.2 degrees (F) above the acceptable range for cold food items which is 40 degrees (F). The findings were verified by Registered Dietician 1 on 02/10/14 at 12:45 p.m..

On the days of the recertification survey based on contract record review and interview, the hospital failed to ensure that it's Infection Control Officer identify all locations and develop policies and procedures to ensure that staff delivering patient care services via a hospital contract receives infection control training and monitoring of infection control practices.

The findings are:

On 2/18/2014 at 10:15 a.m., the Infection Control Officer reported that the hospital's infection control program had no provisions addressing the infection control training requirements or surveillance activities for staff providing patient care services to the hospital's patients. The Infection Control Coordinator reported that there was no communication between the hospital's infection control program and the hospital's contracted entities for coordination of potential employee infection control issues.
The hospital contracts include but are not limited to: dietary services, respiratory services, occupational therapy, environmental services, and physical therapy.


30011

On the days of the hospital recertification survey based on interview, review of personnel file, and governing body minutes, the hospital failed to designate in writing the Infection Control Officer, and the hospital's infection control program failed to encompass the hospital's contracted services employees who provide patient services in the hospital in its infection control surveillance and infection control education program.

The findings are:

On 2/18/14 at 4:00 p.m., the Chief Nursing Officer reported, "I've been here for 8 years, and I know there is no documentation of the Infection Control Officer's appointment anywhere". Review of the Infection Control Officer's personnel file and review of governing body minutes revealed there was no documentation of the appointment.

On the days of the recertification survey based on observations and interviews, the hospital failed to ensure its own staff followed infection control procedures to prevent the potential cross contamination of infectious organisms for 3 of 3 Registered Nurses (RN 1, 2, and 3) and 1 of 1 Nursing Assistants observed providing care and services to patients.

The findings include:

On 02/11/2014 at 8:55 a.m., observations of Registered Nurse(RN) 1 revealed the RN performed hand hygiene for less than 5 seconds before administering medications to Patient 7. RN 1 laid the 60 ml(milliliter) syringe plunger used to administer the patient's medications into the patient's feeding tube on the patient's bed between aspirations of stomach contents and flushing medications. On 02/11/2014 at 9:40 a.m., the findings were verified with RN 1.

On 02/11/2014 at 9:40 a.m., observations of RN 2 showed the RN failed to perform hand hygiene prior to retrieval of Patient 5's medications. After administering the medications to Patient 5, RN 2 performed hand hygiene for less than 5 seconds. RN 2 used a 60 ml syringe plunger to administer the medications via the patient's feeding tube, and then placed the syringe plunger on the table with no barrier. On 02/11/2014 at 10:10 a.m., the findings were verified with RN 2.

Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, titled, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings", reads, "...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...".

Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, titled, "...Hand Hygiene Guidelines Fact Sheet", reads, "...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".




30011

On 02/11/14 from 10:35 a.m. - 10:45 a.m., observations of RN 3 changing an abdominal wound dressing revealed RN 3 performed no hand hygiene after removing his/her gloves twice during the dressing change. The findings were verified by Registered Nurse 3 on 02/11/14 at 10:52 a.m..

On 02/18/14 from 11:30 a.m. - 11:35 a.m., random observations of a fingerstick glucose revealed Certified Nursing Assistant 1 left one patient's room with alcohol swabs, opened gauzes and a lancet devices in a cup and then entered another patient's room with the same supplies in the cup. After entering the second patient's room, Certified Nursing Assistant 1 placed the supplies on the patient's bedside table and obtained the fingerstick glucose.

Guidelines and standard nursing practice in the health care setting set forth in the Recommendation and Reports for the Centers for Disease Control, titled, "Morbidity and Mortality Weekly Report Recommendations and Reports October 25, 2002/Vol 51/No. RR-16 Guideline for Hand Hygiene in Health-Care Settings", reads, "...2. Hand-Hygiene technique...B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacture to hands and rub together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (lB) (90-92,94,411)...".

Guidelines and standard nursing practice in the health care setting set forth by the Centers for Disease Control, titled, "...Hand Hygiene Guidelines Fact Sheet", reads, "...When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry...".

On the days of the hospital recertification survey based on interview, review of personnel files, and review of hospital contracts, the hospital failed to provide patient care staff education on organ procurement donations.

The findings are:

On 02/18/14 at 9:00 a.m., review of the donor hospital's agreement revealed, "k. work cooperatively with Lifepoint to facilitate continuing education to hospital staff on all aspects of donation and document same....".

On 02/18/14 at 9:50 a.m., Registered Nurse 4 revealed, "we may take a class somewhere else and share this information with other nurses....".
On 02/18/14 at 12:40 p.m., Registered Nurse 3 revealed, "only the charge nurses receive organ procurement training. We get training initially....all the nurses rotate for the charge nurse position....". On 02/18/14 at 4:15 p.m., review of the personnel files of Registered Nurse (RN) 3, RN 4 and RN 6, Unit Manager 1, and the Chief Clinical Officer revealed there was no organ procurement training in their files. On 02/18/14 at 5:45 p.m., the Chief Clinical Officer revealed, "the staff probably doesn't have OPO training".