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

1) The hospital failed to:

a) have an effective system in place to ensure the reappointment of current practitioners which resulted in the hospital having no practitioners (physicians and nurse practitioners) providing care and treatment to patients in the hospital that had delineation of privileges, or that had written approval for reappointment to the medical staff for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff, and;

b) ensure credentialing files contained all supporting documents for examination by failing to obtain the collaborative practice agreements for 2 of 2 (S11FNP, S12APRN) APRNs identified as members of the current medical staff (see findings in A-0341).

2) The Medical Staff failed to enforce the Medical Staff bylaws as evidenced by failing to ensure the reappointment of current practitioners was conducted, which resulted in the hospital having no practitioners (physicians and nurse practitioners) providing care and treatment to patients in the hospital that had delineation of privileges, or that had written approval for reappointment to the medical staff for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff (see findings in A-0353).

3) The hospital failed to ensure the medical staff conducted appraisals of its members for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff (100% of Medical Staff) (see findings in A-0340).

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Based on records review and interviews, the hospital failed to ensure effective implementation of the grievance process for prompt resolution of grievances as evidenced by:
1) failing to identify patient complaints regarding food service as grievances for 3 of 3 (#1, #4, #8) sampled patients interviewed out of a total sample of 20, and
2) failing to document, report, and investigate a patient's verbal complaint regarding nursing staff treatment for 1 (#8) of 3 (#1, #4, #8) sampled patients interviewed out of a total sample of 20. Findings:

Review of a hospital policy and procedure titled Grievance, NP-63 (no effective or revision date), provided by S2 DON (Director of Nursing) as current, revealed in part the following:
Definition: Complaint-can be resolved immediately by staff member, Charge Nurse, Director of Nursing, or other qualifying personnel, as well as CEO (Chief Operations Officer).
Grievance- cannot be resolved immediately and is any written or verbal complaint by a patient/family or staff member.
Procedure:
1. When a grievance of any kind is noted, the Grievance Report form is used...the following information is documented when the grievance is received: date and time of incident, date the grievance was received ... the grievance as noted..the name of person who received grievance...date the grievance form was initiated.
2. The grievance form is then referred to the department manager for initial review and action ....This is to be completed within 24 hours. The department manager will make every effort to resolve the problem consistent with needs of the patient and proper management of the Hospital. The patient will be appropriately informed of the department manager's decision or action. Response to the grievance will be made within five working days.
3. The Grievance Report is then forwarded to the CEO for review. If a patient is not satisfied with the decision or action of the department manager, the patient should submit the grievance to the CEO in writing ... The CEO will undertake and appropriate investigation and will inform the patient of the decision or action taken. If the CEO is unable to resolve a patient's grievance, he will provide a written explanation to the patient. The Grievance Report is then forwarded to the Quality Improvement Director for review, completion, and signature. The QI (Quality Improvement) Director will screen all grievances and categorize them. A list of "Perception Criteria" to be used for categorization was listed and included, in part, "patient not treated with respect", "staff's demeanor is negative, patient's comfort not supported by staff", "patient handled roughly by staff", and "hospital food unsatisfactory". Further review revealed the following: "These perceptions refer to the perception of care, not to whether the perceptions are accurate. All grievances that meet the criteria are trended, and the aggregate data is forwarded to the appropriate committees."

1) failing to identify patient complaints regarding food service as grievance:
In an interview 3/5/13 at 12:10 p.m., Patient #1 reported that the food served by the hospital did not taste good and there was no variety. He stated he had reported this to staff members, but could not remember exactly to whom he had reported. Patient #1 said he was told that other than getting him a sandwich or cereal there was nothing that could be done.
In an interview 3/5/13 at 10:05 a.m., S1Assistant Administrator reported that the Hospital did not have a Grievance Log as there had been no grievances or complaints in the last year.
In an interview on 03/07/13 at 9:10 a.m., Patient #4 stated the food served by the hospital did not taste good and he received the same food over and over. Patient #4 stated he had reported his complaint to the staff, but there was nothing they could do about it.
In an interview on 03/07/13 at 9:46 a.m., Patient #8 stated the food served by the hospital did not taste good, there was no variety in the foods served. Patient #8 complained the food was at times cold, but the staff would not warm the food in the microwave once the food was placed in his room. Patient #8 stated that was due to infection precautions. Patient #8 stated one day he received tuna fish and he found a long strand of hair in it. Patient #8 stated after that incident, he did not eat much from the hospital. Patient #8 stated his family brought him a smoothie blender (observed at patient's bedside) and he made himself a smoothie with ice, ice cream and fruit. Patient #8 stated he had voiced his concerns about the food to the staff, but has not received any follow up from the staff.
In an interview on 3/05/13 at 4:03 p.m., S6RD (Registered Dietician) reported that most of the patients complained that the food wasn't good and there wasn't enough variety. She reported that she talked to the patients, and offered a sandwich , but explained that the food was brought in from another facility and there was not anything that could be done. S6RD said that the substitution of a sandwich was not of equal nutritional value to the meals. She further stated that if the patients were not satisfied, and some are not, she did not fill out a grievance.
In an interview on 3/07/13 at 3:15 p.m., S2DON verified that the hospital received a lot of complaints from patients about the food not tasting good and not enough variety. When asked if these complaints had been addressed and resolved she replied that the patients could get a nice Chef's salad, a sandwich, or some cereal. The DON was asked if the patients were happy with that as a resolution, to which she replied, "Well, no; not all of them." After review of the Grievance Policy and Procedure, she verified that the unresolved complaints should have been treated as grievances, documented, and processed as per the policy and procedure. The DON reported that administration was aware of the many complaints about the food.

2) failing to document, report, and investigate a patient's verbal complaint regarding nursing staff treatment:

In an interview on 03/07/13 at 9:46 a.m., Patient #8 stated the nurse on the night shift had a bad attitude and "Yanked" his PICC (Peripherally Inserted Central Line) 2-3 days ago. Patient #8 stated he was concerned the line had moved and could come out. Patient #8 stated he had reported his concern to the charge nurse and he stated he was going to file a report on the incident. Patient #8 stated he had not heard any response from the staff.

In an interview on 03/07/13 at 2:05 p.m., S2 Director of Nursing (DON) was asked if she had received any complaints regarding staff treatment by a night shift nurse in the last week. S2DON stated she had not. S2DON was informed a patient had voiced a concern about staff treatment by a night shift nurse and indicated the concern was reported to the charge nurse and the charge nurse told him he would file a report. S2DON stated she had not been notified of any patient concerns in the last week. S2DON stated she would contact the charge nurse.

In an interview on 03/07/13 at 5:00 p.m., S2DON stated she had been unable to contact the charge nurse, but stated she had spoken with S19LPN, who worked the night shift and S19LPN stated Patient #18 had voiced a concern to her about the way she handled his PICC line. S2DON stated S19LPN told her the patient complained that S19LPN jerked his PICC line. S2DON stated S19LPN did not report the patient's complaint to her or the charge nurse. S2DON stated she informed S19LPN to come into the hospital to discuss the incident and how to handle patient complaints.

Based on records review and interviews, the hospital failed to use collected data to identify opportunities for improvement , and develop and implement corrective actions for medication errors and infection control related to an unclean physical environment.

Findings:


Review of an Infection Prevention and Control Inspection (Checklist) for 1/23/13 and 2/25/13 , provided by S8Infection Control revealed the following:

A list of items to be inspected were: Rooms clean-no visible dust on surfaces, nothing should be stored on floors, room doors close securely/tightly, vents are clean with no visible dust, holes, dings in the wall have been repaired, curtains/blinds on windows are clean, floors are clean, toilets flush, adequate amount of soap and paper towels at each sink, waste bins are available in all rooms, refrigerators clean/items dated, refrigerator temperature charts are up to date, sharps containers are ready for use, red hazardous waste bins are available on every unit, hazardous waste bins are located in soiled utility room and are covered appropriately, soiled linen is disposed of properly, no food items in patient rooms, showers have been activated and the shower head is in place with no visible mold, and janitor closet and trash chute area are clean.

- 1/23/13 Rooms 111-114 were listed as having been inspected for cleanliness/infection control. All items on the form were checked with a check mark, except refrigerator items marked with "N/A" (not applicable). No documentation was noted in the exception or description columns.

-2/25/13 Rooms 100, 105, Therapy : All items had a check mark with the exception of Floors are clean for 100, 105 and P.T. (Physical Therapy) , description of dirty floors, Toilets flush for 100 and 105, description of dirty bathrooms, adequate amount of soap and paper towels at each sink for P.T., description of "needs hand towels". N/A was noted for " Hazardous waste bins are located in soiled utility room and are covered appropriately"; "Showers have been activated and the shower head is in place", and "Janitor closet and trash chute area are clean".

The following observations were made 3/7/13 between 10:20 a.m. and 10:45 a.m., with S8Infection Control:

Room 100: A dried medium brown transparent area on floor under the bedside table and between the table and bed was observed. There were 3 round spots of bright red on the floor at the upper edge of the bed closest to the hallway door. Along the baseboards beside and behind the bed a thick yellowish dried substance was noted in a drip and splatter pattern on the wall beside and behind the headboard of the bed. There were 3 small pieces of paper under the bed. The call bell hand piece was noted to be covered in a substance that was off white/slightly yellow in color, was dried, and flaking. In the bathroom there was hair and dust on the floor by the toilet. The bathroom floor had a dark brown spot approximately 1-2 cm (centimeters) in diameter. There was a roll of brown paper hand towels sitting in the windowsill of the bathroom. No paper towels were in the holder in the bathroom. In an interview 3/7/13 at 10:28 a.m. S8Infection Control stated that the spill on the floor and wall, as well as on the call bell looked like old tube feeding formula. She verified the above findings, and that she had inspected Room 100 on her environmental rounds 1/3/13 and 2/25/13.


Room 105: Splatters of dried translucent light brown substance were noted on the wall by the head of the bed. The empty sharps box holder was observed to have a thick layer of dust on it. The top of the sink containing the facet and handles, in the bathroom, was observed to have a very thick build-up of a whitish substance over half of the porcelain. Both the far wall of the bathroom and the far inside wall of the toilet had spots of light brown in a spatter pattern. The bathroom tissue (enclosed dispenser) was taped closed with a large piece of cloth medical tape. In an interview 3/7/13 at 10:26 a.m. S8Infection Control verified the above findings, and that she had inspected Room 105 on her environmental rounds 1/3/13 and 2/25/13.

Room 110- The call bell control was covered with a dried flaky substance. There was dust noted rolling on floor. In a trash can beside the patient bed was a yellow/light brown colored long strip of cotton gauze. The gauze strip was noted to be white and curved at one end, as if it had been tied in a knot. A dried light brownish white opaque substance was noted on the wall by the bed headboard in drip and splatter patterns. A band of dust was observed in one corner of the room approximately 4-5 inches long and attached to the ceiling at either end of the band. In the bathroom the toilet was noted to be dirty. A half empty roll of brown paper toweling was observed in the window sill. In an interview 3/7/13 at 10:24 a.m. S8Infection Control verified the above findings. She stated that the residue noted on the call bell handle and the wall looked like it might be old tube-feeding formula.

Patient Nourishment Room: The wall next to the garbage can had splatters of a light red substance and a medium brown substance. The top of the garbage can had part of it's hinged covers cracked and broken off. The remaining pieces of garbage top had splatters of a light red substance, medium brown substance and off-white substance. In the refrigerator identified as used for patient nourishments the following were observed: 3 plastic bags, one which contained a bowl of unidentified contents, another with unidentified contents, and one with fruit. None of the bags were labeled with a name, date, or contents. There were 2 unlabeled and dated plastic zipped containers, a package of undated Yoplait yogurt-6 oz (ounces), a pint of half and half with "Mr." and a surname written on it with no date opened. The name on the half and half carton did not match any current patients, and a stamped expiration date was 12/24/12. In the door section of the refrigerator was an approximately 1/2 full 18 oz. bottle of barbeque sauce with no name or date on it. The seal around the refrigerator door had numerous pink and brown spots on it. The handle was noted to have light brown dirty marks on it. The kitchen sink was noted to have a large amount of build up of substance surrounding the facet and handle areas. In an interview 3/5/13 at 10:30 a.m. S8Infection Control verified the above findings. She stated that while she considered it OK to have staff food in the refrigerator, all food should be labeled and dated. She confirmed that the dirty areas in the refrigerator and in the kitchen were an infection control concern, and had not been identified by the herself or the hospital.

In an interview 3/7/13 at 9:50 a.m. S8Infection Control reviewed the infection control documents and confirmed that there was not an investigation of the HAIs or a plan to prevent future infections. The Infection Control Director reported that she only worked 4-6 hours a week, in the evenings. She stated that she and other staff made monthly environmental rounds on random rooms and areas, but that she did not report her findings until several weeks later when she submitted her report to the DON or Assistant Administrator. She confirmed that when she found a room or area dirty or in ill repair she did not immediately report it, or follow-up to see that corrections were made. S8Infection Control verified that the environmental issues were not incorporated into the Quality Assurance program.



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Review of the medication error rates presented by the hospital revealed the following error rate calculations for 2012:

Doses of PO (by mouth) medications for 2012 = 57, 679
Medication errors = 1
Medication error rate- 1/57,679= 1.7= 2 % error rate.

Doses of IV (intravenous) medications for 2012 = 43,964
Medication errors= 1
Medication error rate- 1/43,964= 2.3= 2%

Review of monthly reports from Pharmacy "A" to the hospital about medication error rates for 2012 revealed the pharmacy had identified the following errors:

January- None

February- 1 route error by pharmacy. Discovered by pharmacy.

March- 1 dose error by facility. Discovered by pharmacy.

April- 1 incorrect patient. Discovered by pharmacy

May- None

June- 1 omission, 1 interaction missed. Discovered by pharmacy.

July, August, September- None

October- 1 order scratched through by hospital staff. Discovered by pharmacy.

November- 1 incorrect medication given. Reported by Hospital.

December- 1 incorrect medication given. Discovered by pharmacy.

In an interview on 3/6/13 at 9:30 a.m., with S15PharmacyCompliance Nurse, she stated the pharmacy had recognized 8 medication errors in 2012. She said 7 of the errors were discovered by the pharmacy and 1 error was reported by the facility. S15PharmacyCompliance Nurse stated the facility should have been reporting to the pharmacy when they discovered an error. She stated the facilities report of having 2 medication errors in a year with 101,643 medications dispensed seemed unreasonably low. S15PharmacyCompliance Nurse also stated when the monthly medication error reports were sent to the hospital, an F by the error number meant it was discovered and reported by the facility and a P by the error number meant it was discovered by the pharmacy.

In an interview on 3/6/13 at 10:10 a.m. with S2DON, she stated she had 2 medication errors in 2012. She also stated her medication error rate was 2%. She said she calculated that number by dividing 2 errors by the total of medications given which was 2 divided by 101,643 which equaled 1.7%. When recalculated, S2DON verified the actual number of 2 divided by 101,643 was 0.00001968. She also stated she was not aware the pharmacy had discovered 7 medication errors in 2012 because she did not realize the P behind the medication error number on the pharmacy reports meant an error had been discovered by the pharmacy. S2DON said her medication error data collection was not accurate. S2DON also stated she had collected the data for Quality purposes, but did not do anything with the data.

Based on review of policy/procedure, Medical Executive Committee (MEC) minutes, credentialing files, and staff interview, the hospital failed to ensure the medical staff conducted appraisals of its members for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff.

Findings:

Review of the policy and procedure titled, Reappointment to Medical Staff, reviewed date of 05/27/10, provided by S1 Assistant Administrator as current, revealed in part the following: All Medical Staff will be reappointed to the Medical Staff in a timely and appropriate manner as outlined in the Bylaws.

Procedure: I. Reappointment Process: A. Four months prior to the ending of an appointment term the CEO (Chief Executive Officer) or designee shall send a reappointment packet to the Medical Staff member and request: Application to be completed, signed and returned within three weeks, updated privilege sheet.... The letter accompanying the packet should state that failure to return the appointment application shall constitute voluntary resignation from the Medical Staff. b. When all the following is received the reappointment application may be presented to MEC (Medical Executive Committee): Completed appointment application, updated clinical privilege form, hospital reference letter, references from two peers, references and reappraisal from Medical Director or President of Medical Staff, verification of health status, and practitioner profile....

Review of the MEC Meeting Minutes dated 03/31/13 revealed in part the following: Credentialing - All medical staff credentials (Certificate of Insurance, CDS {Controlled Dangerous Substance}, DEA {Drug Enforcement Agency} licensure) are up to date and have been privileged through the medical staff process. All medical staff evaluations are up to date.

Review of the MEC Meeting Minutes dated 07/17/12 and 10/16/12 revealed in part the following: Credentialing - All medical staff credentials are up to date and have been privileged through the medical staff process. All medical staff evaluations are up to date.


S12APRN
Review of the credentialing file for S12APRN revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the credentialing file revealed the only appraisal documented by a member of the medical staff was on 08/31/2010.

In a face-to-face interview on 03/07/13 at 3:25 p.m., S1 Assistant Administrator reviewed the credentialing file for S12APRN and verified there were no appraisals by a member of the medical staff since 08/31/2010. S1 Assistant Administrator verified S9Physician, S10Physician, S13Physician, S11FNP, and S12APRN were the only practitioners on the medical staff of the hospital.


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S11FNP
Review of the credentialing file for S11FNP revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the credentialing file revealed the only appraisal documented by a member of the medical staff was on 04/10/2010.

In a face-to-face interview on 03/07/13 at 3:15 p.m., S1 Assistant Administrator reviewed the credentialing file for S11FNP and verified there were no appraisals by a member of the medical staff since 04/10/2010.

S9Physician
Review of the credentialing file for S9Physician revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the credentialing file revealed the most recent appraisal documented by a member of the medical staff was on 03/15/2010.

In a face-to-face interview on 03/07/13 at 3:05 p.m., S1 Assistant Administrator reviewed the credentialing file for S9Physician and verified there were no appraisals by a member of the medical staff since 03/15/10.

S10Physician
Review of the credentialing file for S10Physician revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the credentialing file revealed the only appraisal documented by a member of the medical staff was on 05/21/08.

In a face-to-face interview on 03/07/13 at 3:10 p.m., S1 Assistant Administrator reviewed the credentialing file for S10Physician and verified there were no appraisals by a member of the medical staff since 05/21/2010.




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Review of the credentials file for (S13)Physician revealed the initial appointment to the medical staff by the Governing Board was dated April 5, 2010. Review of the credentialing file revealed the most recent appraisal document was dated 09/18/06.
In a face-to-face interview on 03/07/13 at 3:15 p.m., (S1)Assistant Administrator reviewed the credentialing file for (S13)Physician and verified there were no appraisals by a member of the medical staff since 09/18/06.

Based on review of Medical Staff By-Laws, Policies and Procedures, credentialing files, Medical Executive Committee (MEC) minutes, and staff interview, the hospital failed to:

1) have an effective system in place to ensure the reappointment of current practitioners which resulted in the hospital having no practitioners (physicians and nurse practitioners) providing care and treatment to patients in the hospital that had delineation of privileges, or that had written approval for reappointment to the medical staff for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff, and;

2) ensure credentialing files contained all supporting documents for examination by failing to obtain the collaborative practice agreements for 2 of 2 (S11FNP, S12APRN) APRNs identified as members of the current medical staff.

Findings:

1) Reappointment of Medical Staff:

Review of the Medical Staff By-Laws provided by S1 Assistant Administrator as current, revealed in part the following: ....

Section 3.5. Duration of Appointment.
3.5.1. Duration and renewal of Initial and Modified Appointment. all initial appointments, and modification of appointments pursuant to Section 6.6 may be for a period extending for up to two (2) years from the month of appointment.
3.5.2. Reappointments to any category of the medical staff shall be for a period of not more than two years....

5.2.10. Procedure for Appointment and Granting of Privileges: Application for appointment, reappointment and privileges for Allied Health Professional and physician assistants shall be submitted and processed in the same manner as provided in Articles 6. and 7. for medical staff membership and clinical privileges....

Article VI: Procedures for appointment and reappointment
Section 6.1 General Procedure. The medical staff, through its services, committees and officers, shall investigate, verify and consider each application of appointment or reappointment to any staff status and each request for modification of staff status and shall adopt and transmit recommendations thereon to the Governing Board....

Review of the policy and procedure titled, Reappointment to Medical Staff, reviewed date of 05/27/10, provided by S1 Assistant Administrator as current, revealed in part the following: All Medical Staff will be reappointed to the Medical Staff in a timely and appropriate manner as outlined in the Bylaws.

Procedure: I. Reappointment Process: A. Four months prior to the ending of an appointment term the CEO (Chief Executive Officer) or designee shall send a reappointment packet to the Medical Staff member and request: Application to be completed, signed and returned within three weeks, updated privilege sheet.... The letter accompanying the packet should state that failure to return the appointment application shall constitute voluntary resignation from the Medical Staff. b. When all the following is received the reappointment application may be presented to MEC (Medical Executive Committee): Completed appointment application, updated clinical privilege form, hospital reference letter, references from two peers, references and reappraisal from Medical Director or President of Medical Staff, verification of health status, and practitioner profile....

Review of the MEC Meeting Minutes dated 03/31/13 revealed in part the following: Credentialing - All medical staff credentials (Certificate of Insurance, CDS {Controlled Dangerous Substance}, DEA {Drug Enforcement Agency} licensure) are up to date and have been privileged through the medical staff process....

Review of the MEC Meeting Minutes dated 07/17/12 and 10/16/12 revealed in part the following: Credentialing - All medical staff credentials are up to date and have been privileged through the medical staff process....


S12APRN
Review of the credentialing file for S12APRN revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the Delineation of Privileges for Internal Medicine for S12APRN revealed the privileges were approved on 04/01/10. There was no documented evidence of an application for reappointment, request for clinical privileges, references, or reappraisal from the Medical Director or the Medical Staff president. There was no documented evidence of a Medical Staff recommendation for reappointment and there was no evidence of Governing Body reappointment to the Medical Staff.

In a face-to-face interview on 03/07/13 at 3:25 p.m., S1 Assistant Administrator reviewed the credentialing file for S12APRN. S1 Assistant Administrator stated the appointment term for medical staff members was 2 years. S1 Assistant Administrator stated she thought all she had to do was verify the practitioner was licensed and check the data bank. S1 Assistant Administrator verified there was no documented evidence of any current delineation of privileges or Governing Body reappointment to the Medical Staff for S12APRN. After reviewing the hospital policy and procedure for reappointment to the medical staff, S1 Assistant Administrator stated she did not know the medical staff had to go through a reappointment process. S1 Assistant Administrator verified no physician or nurse practitioner (APRN) on the current medical staff had been reappointed since their initial appointments in 2010. S1 Assistant Administrator verified S9Physician, S10Physician, S13Physician, S11FNP, and S12APRN were the only practitioners on the medical staff of the hospital.

S9Physician
Review of the credentialing file for S9Physician revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the Delineation of Privileges for the body system of Musculoskeletal for S9Physician revealed the privileges were approved on 04/01/09. There was no documented evidence of an application for reappointment, request for clinical privileges, references, or reappraisal from the Medical Director or the Medical Staff president. There was no documented evidence of a Medical Staff recommendation for reappointment and there was no evidence of Governing Body reappointment to the Medical Staff.

In a face-to-face interview on 03/07/13 at 3:05 p.m., S1 Assistant Administrator reviewed the credentialing file for S9Physician. S1 Assistant Administrator stated the appointment term for medical staff members was 2 years. S1 Assistant Administrator verified there was no documented evidence of any current delineation of privileges or Governing Body reappointment to the Medical Staff for S9Physician.

S10Physician
Review of the credentialing file for S10Physician revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the Delineation of Privileges for S10Physician revealed the privileges were approved on 06/10/08. There was no documented evidence of an application for reappointment, request for clinical privileges, references, or reappraisal from the Medical Director or the Medical Staff president. There was no documented evidence of a Medical Staff recommendation for reappointment and there was no evidence of Governing Body reappointment to the Medical Staff.

In a face-to-face interview on 03/07/13 at 3:10 p.m., S1 Assistant Administrator reviewed the credentialing file for S10Physician. S1 Assistant Administrator stated the appointment term for medical staff members was 2 years. S1 Assistant Administrator verified there was no documented evidence of any current delineation of privileges or Governing Body reappointment to the Medical Staff for S10Physician.

S11FNP
Review of the credentialing file for S11FNP revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the Delineation of Privileges for S11FNP revealed S13Physician had signed as the applicant on 2/21/2013. There was no signature on the delineation of Privileges for the Medical Executive Committee Chairperson or S11FNP. There was no documented evidence of an application for reappointment, request for clinical privileges, references, or reappraisal from the Medical Director or the Medical Staff president. There was no documented evidence of a Medical Staff recommendation for reappointment and there was no evidence of Governing Body reappointment to the Medical Staff.

In a face-to-face interview on 03/07/13 at 3:15 p.m., S1 Assistant Administrator reviewed the credentialing file for S11FNP. S1 Assistant Administrator stated the appointment term for medical staff members was 2 years. S1 Assistant Administrator verified there was no documented evidence of any current Governing Body reappointment to the Medical Staff for S11FNP or a signed copy of the Delineation of Privileges by the Medical Executive Committee and S11FNP.


2) Failing to obtain collaborative practice agreements:

Review of the Medical Staff By-Laws provided by S1 Assistant Administrator as current, revealed in part the following: Article V: Allied Health Professional

Section 5.1. Qualifications: The holding of staff status as an allied health professional, or the exercise of temporary membership, is a privilege which shall be extended only to allied health professionals who:

5.1.1. Document their background, experience, training, current competence, health status with sufficient adequacy to demonstrate to the Medical Staff and the Board that any patient treated by them will receive care of the generally accepted level of quality and efficiency in the community.

5.1.2 Document compliance with the following requirements: ....2. Hold all licenses and certifications required by law in order to engage in their respective profession; 3. Are professionally qualified to provide services which need to be provided at the hospital as such need is determined to exist form time to time by the board....

S12APRN
Review of the credentialing file for S12APRN revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Further review of the credentialing file revealed no documented evidence of the collaborative practice agreement (formal written statement addressing the parameters for the collaborative practice which are mutually agreed upon by the APRN and one or more physicians) for S12APRN.

In a face-to-face interview on 03/07/13 at 3:25 p.m., S1 Assistant Administrator reviewed the credentialing file for S12APRN. S1 Assistant Administrator verified there was no documented evidence of the collaborative practice agreement for S12APRN.

S11FNP
Review of the credentialing file for S11FNP revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Further review of the credentialing file revealed no documented evidence of the collaborative practice agreement (formal written statement addressing the parameters for the collaborative practice which are mutually agreed upon by the FNP and one or more physicians) for S11FNP.

In a face-to-face interview on 03/07/13 at 3:15 p.m., S1 Assistant Administrator reviewed the credentialing file for S11FNP. S1 Assistant Administrator verified there was no documented evidence of the collaborative practice agreement for S11FNP.








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Review of the credentialing file for (S13)Physician revealed the initial appointment to the medical staff by the Governing Board was dated April 5, 2010. Review of the Delineation of Privileges for (S13)Physician revealed the privileges were approved on April 5, 2010. Further review revealed there was a " Delineation of Privileges " application completed on 02/21/13 by (S13)Physician, and the application was not signed by the Medical Executive Committee Chairperson. There was no documented evidence requesting references, reappraisals from the Medical Staff President. There was no documented evidence of a medical staff recommendation for reappointment, and there was no evidence of Governing Body reappointment to the medical staff.
In a face-to-face interview on 03/07/13 at 3:15 p.m., (S1)Assistant Administrator indicated the appointment term for medical staff members was two years. (S1)Assistant Administrator reviewed the credentialing file for (S13)Physician and confirmed there was no documented evidence of any current delineation of privileges or Governing Body reappointment to the medical staff for (S13)Physician.

Based on review of Medical Staff By-Laws, Medical Executive Committee (MEC) minutes, credentialing files, and staff interview, the Medical Staff failed to enforce the bylaws as evidenced by failing to ensure the reappointment of current practitioners was conducted which resulted in the hospital having no practitioners (physicians and nurse practitioners) providing care and treatment to patients in the hospital that had delineation of privileges, or that had written approval for reappointment to the medical staff for 3 of 3 physicians (S9Physician, S10Physician, S13Physician) identified as current medical staff, and 2 of 2 (S11FNP, S12APRN) APRNs (Family Nurse Practitioner/Advance Practice Registered Nurses) identified as current medical staff. Findings:

Review of the Medical Staff By-Laws provided by S1 Assistant Administrator as current, revealed in part the following: ....

Section 3.5. Duration of Appointment.
3.5.1. Duration and renewal of Initial and Modified Appointment. all initial appointments, and modification of appointments pursuant to Section 6.6 may be for a period extending for up to two (2) years from the month of appointment.
3.5.2. Reappointments to any category of the medical staff shall be for a period of not more than two years....

5.2.10. Procedure for Appointment and Granting of Privileges: Application for appointment, reappointment and privileges for Allied Health Professional and physician assistants shall be submitted and processed in the same manner as provided in Articles 6. and 7. for medical staff membership and clinical privileges....

Article VI: Procedures for appointment and reappointment
Section 6.1 General Procedure. The medical staff, through its services, committees and officers, shall investigate, verify and consider each application of appointment or reappointment to any staff status and each request for modification of staff status and shall adopt and transmit recommendations thereon to the Governing Board....

Section 6.5 Reappointment Process

6.5.1. Information Form for Reappointment. The Chief Executive Officer shall, at least ninety days prior to the expiration date of the present staff status appoint of each persons holding the same, provide such person with an interval information form for use in considering reappointment. Each such person who desires reappointment shall, at least sixty days prior to such expiration date, send his interval information form to the Chief Executive Officer. Failure to so return the form shall be deemed a voluntary resignation from staff status and shall result in automatic termination of staff status and together with all clinical privileges at the expiration of such person's current term....

6.5.4. Credentials Function Action: The Medical Executive Committee shall review each information form and all other relevant information available to it and shall forward for approval of recommendation to the Board its report and recommendation that appointment be either renewed, renewed with modified staff status and/or clinical privileges, renewed with special conditions or terminated....

Review of the MEC Meeting Minutes dated 03/31/13 revealed in part the following: Credentialing - All medical staff credentials (Certificate of Insurance, CDS {Controlled Dangerous Substance}, DEA {Drug Enforcement Agency} licensure) are up to date and have been privileged through the medical staff process....

Review of the MEC Meeting Minutes dated 07/17/12 and 10/16/12 revealed in part the following: Credentialing - All medical staff credentials are up to date and have been privileged through the medical staff process....


S12APRN

Review of the credentialing file for S12APRN revealed the initial appointment to the Medical Staff by the Governing Board was dated 04/05/2010. Review of the Delineation of Privileges for Internal Medicine for S12APRN revealed the privileges were approved on 04/01/10. There was no documented evidence of an application for reappointment, request for clinical privileges, references, or reappraisal from the Medical Director or the Medical Staff president. There was no documented evidence of a Medical Staff recommendation for reappointment and there was no evidence of Governing Body reappointment to the Medical Staff.

In a face-to-face interview on 03/07/13 at 3:25 p.m., S1 Assistant Administrator reviewed the credentialing file for S12APRN. S1 Assistant Administrator stated the appointment term for medical staff members was 2 years. S1 Assistant Administrator stated she thought all she had to do was verify the practitioner was licensed and check the data bank. S1 Assistant Administrator verified there was no documented evidence of any current delineation of privileges or Governing Body reappointment to the Medical Staff for S12APRN. After reviewing the hospital policy and procedure for reappointment to the medical staff, S1 Assistant Administrator stated she did not know the medical staff had to go through a reappointment process. S1 Assistant Administrator verified no physician or nurse practitioner (APRN) on the current medical staff had been reappointed since their initial appointments in 2010. S1 Assistant Administrator verified S9Physician, S10Physician, S13Physician, S11FNP, and S12APRN were the only practitioners on the medical staff of the hospital.

Based on records review and interviews, the hospital failed to ensure that medical records services were appropriate to the scope and complexity of the services performed by failing to ensure that the medical records department was supervised by a qualified medical records practitioner.
Findings:
Review of Hospital Licensing Standards (LAC) 48:I.Chapter 93), Subchapter H. Medical Records Services, 9387. Organization and Staffing, revealed that medical records shall be under the supervision of a medical records practitioner (i.e., registered record administrator or accredited record technician) on either a full-time, part-time or consulting basis.
In a face-to-face interview on 03/6/13 at 1:15 p.m., (S1)Assistant Administrator indicated that (S4)Medical Records was the Director of Medical Records. She also indicated (S4)Medical Records had a " RHIT (registered health information technician) degree." She further indicated that (S4)Medical Records is the only employee assigned in the medical records department.
Review of the personnel file for (S4)Medical Records revealed there was no medical record training or certification. Further review revealed that (S4)Medical Records had a certificate from the " National Healthcareer Association " indicating successful completion of the course for a " Certified Medical Administrative Assistant " as well as a completed course in " Certified Billing and Coding Specialist. "
In a face-to-face interview on 03/6/13 at 1:45 p.m., (S4)Medical Records indicated that she went to school for " medical records through Job Corp. " She also indicated there are no other employees assigned to the medical records department. She further indicated she reports directly to (S1)Assistant Administrator.

Based on records review and interview, the hospital failed to have a system of coding and indexing medical records that allowed for timely retrieval by diagnosis and procedure.
Findings:
In a face-to-face interview on 03/6/13 at 1:05 p.m., S4Medical Records indicated the hospital did not have an electronic medical record system that enabled medical record information to be accessed by patient's diagnoses or procedures. S4Medical Records further indicated the patient's medical record information is accessed by patient's medical record number or patient's name.

Based on interview and records review, the hospital failed to ensure all physicians' orders were dated and timed consistent with the Hospital's Governing Body By-Laws for 7 (#5, #7, #9, #10, #12, #13, #20) of 20 (#1- #20) patients sampled.

Findings:

Review of the Governing Body By-Laws presented by the hospital as current revealed the following specifications, in part, for physician orders that were given verbally or electronically:
All physician orders that are verbal or electronically transmitted or otherwise, shall be timed, signed and dated, (or countersigned) as necessary within 10 days of said order.

Patient #5
Review of the medical record for Patient #5 revealed he was a 54 year old male who had been admitted to the hospital on 1/25/13 with diagnosis which included a sacral decubitus ulcer. Further review of the Physician's Orders for Patient #5 revealed the following telephone orders:

1/25/13 at 1945- Patient #5's admission orders.

1/25/13 at 0900- Vicodin (analgesic) 7.5/750 x (times) 1 dose.

Further review of the Physician's Orders for Patient #5 revealed S13Physician had signed the above mentioned telephone orders, but had not dated or timed the signature.

Patient #7
Review of the medical record for Patient #7 revealed the following telephone orders:

1/25/13 at 1230- Admission orders

1/29/13 at 1819- D/C (discontinue) peripheral IV (intravenous catheter). OK to use PICC (peripherally inserted central catheter) line.

Further review of the physician's orders revealed the above mentioned telephone orders had been authenticated by S13Physician, but had not been timed or dated.

Patient #9
Review of the medical record for Patient #9 revealed he had been admitted to the hospital on 2/14/13 with diagnosis which included urosepsis, urinary retention, and acute renal failure.
Further review revealed the following telephone order:

2/14/13 at 1945- Crestor (Cholesterol medication) 10mg po (by mouth) every H.S. (hour of sleep)

Further review of the Physician's Orders revealed the above mentioned telephone order had been authenticated by S13Physician, but had not been dated or timed.

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the facility on 1/29/13 with diagnosis which included a wound on the left foot, diabetes, and renal failure.
Further review revealed the following telephone orders:

2/3/13 at 1345- Cipro (antibiotic Cipro floxacin) 400mg (milligrams) IVPB (Intravenous Piggy Back) Q24 hr (every 24 hours). Give after dialysis. D/C (discontinue) Cipro 200mg IVPB Q24 hr.

2/8/13 at 11:45 a.m.- 1) Administer Cipro 400mg IVPB X 1 now. 2) Start Cipro 400mg IVPB Q24 and administer at 0200 daily stating on 2/9/13.

1/30/13 at 0730- Lantus (Insulin) 50 units SQ HS (subcutaneous injection at hour of sleep).

Further review revealed the three abovementioned telephone orders had been authenticated by S13Physician, but he had not dated or timed the signature.

In an interview on 3/16/13 at 2:45 p.m. with S2DON, she stated when physicians verify telephone orders, they should be timing and dating their signatures. S2DON stated S13Physician has always had a problem with remembering to time and date his orders at the hospital because the other hospital he works at has dictation which automatically times and dates his entries.








17091

Patient #20
Review of the clinical record for Patient #20 revealed the patient was admitted to the hospital on 07/26/12 and left AMA (Against Medical Advice) on 09/03/12. The patient's diagnoses included Multiple Decubitus and Sepsis.

Review of the physician's orders dated 08/22/12 (no time) revealed orders for Lasix 40 mg. now and BMP (Basic Metabolic Panel) in a.m. The physician's order revealed a signature, but no documented evidence of the time the order was written.

In an interview on 03/07/13 at 11:30 a.m., S2DON verified the physician had written the above order, but failed to include the time the order was written.


31048

Patient #13

Review of the medical record for Patient #13 revealed he was admitted to the hospital on 02/06/13 with a diagnosis of infected decubitus ulcer. Patient #13 was admitted for wound care and intravenous antibiotic therapy.

Further review of the physician's orders for Patient #13 revealed the following telephone orders:
02/06/13 at 1800: Ampicillin-Sulbactam 3 grams in normal saline, 0.9% 100 milliliters IVPB (intravenous piggy back) every 6 hours; and TPN (total parenteral nutrition) with 5% AA (amino acids) and 20% glucose with regular electrolytes at 60 cc's (cubic centimeter) per hour.
02/06/13 at 2020: Order clarification: Vitamin D, 1000 units by mouth daily
02/07/13 at 0925: Amikacin 300 mg (milligrams) in Dextrose 5% at 100 ml (milliliters) per hour IVPB (intravenous piggy back) every 12 hours.
02/11/13 at 1405: Wound care BID (twice per day) and PRN (as needed) with 1/2 strength Dakins solution; and change iron tablet 325 mg (milligrams) by mouth TID (three times per day).
Further review of the physician's orders for Patient #13 revealed S13Physician had signed the above mentioned telephone orders, but had not dated or timed the signatures.

Patient #12

Medical record review for Patient #12 revealed she was admitted to the hospital on 01/23/13 with a diagnosis of neurosyphilis. Patient #12 was admitted to the hospital for intravenous antibiotic therapy.

Further review of the physicians orders for Patient #12 revealed the following telephone orders:
02/05/13 at 1600: D/C (discontinue) PCN (penicillin) 3 million units IVPB (intravenous piggy back every 4 hours.
02/05/13 at 1800: D/C (discontinue) Primaxin IVPB (intravenous piggy back)
Primaxin 250 mg (milligrams) IM (intramuscular) every 8 hours.
Further review of the physician's orders for Patient #12 revealed S13Physician had signed the above mentioned telephone orders but had not dated or timed the signatures.

In a face-to-face interview on 03/07/13 at 3:10 p.m., S2DON verified that the physician verbal orders on the above mentioned patients were not dated and timed.

Based on interview and records review, the hospital failed to ensure informed consent forms were properly obtained as evidenced by patient's signing blank consents for medical or surgical procedures for 3 (#2, #4, #13) of 20 (#1- #20) patients sampled, restraint use for 5 (#5, #10, #12, #16 #17) of 20 (#1- #20) patients sampled, and advance directives for 3 (#5, #12, #16) of 20 patients sampled (#1- #20).

Findings:

Review of the hospital policy titled Informed Consent, Policy: NP-71, revealed in part:
(The Hospital) shall provide the patient with the adequate and appropriate information in order that he/she can make an informed decision regarding surgery, and invasive procedures and treatments. All personnel will be aware of the policies and implication of consents and that those consents are properly obtained and completed ...

Consent is defined as a free, rational act, which presupposes knowledge of the thing to which consent is given. In principle, one giving informed consent means that the signer knows what he/she is signing, knows what is to be done, understands the risks involved, and has the authority to sign. Routine informed consent in advance of procedures, which have a substantial risk, is to guard the patient against unsanctioned surgery, procedures, and treatments ...

Patient #4

Medical record review revealed Patient #4 was admitted to the hospital on 2/11/13 with diagnosis which included Osteomyelitis (bone infection).

Review of the document in Patient #4's medical record titled Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information revealed none of the information had been written in the following blanks: Description, nature of the treatment/procedure; Purpose, Patient Condition; Material risks of treatment procedure; Therapeutic alternatives, risks associated therewith, and risks of no treatment; Name of authorized physician or group.

Further review revealed the document had the following statements listed:

I have read and understand all information set forth in this document and all blanks were filled in prior to signing. This authorization for and consent to medical treatment or surgical procedure is and shall be valid until revoked.

I acknowledge that I have had the opportunity to ask any questions about the contemplated medical procedure or surgical procedure described in item 2 of this consent form, including risk and alternatives, and acknowledge that my questions have been answered to my satisfaction.

Further review of the Patient Consent to Medical or Surgical Procedure and Acknowledgement or Receipt of Medical Information document revealed it had been signed by Patient #4. No date was written on the consent.

In an interview on 3/6/13 at 2:30 p.m. with S2DON, she verified a surgical consent for Patient #4 had been signed by Patient #4 although no information about a specific surgical procedure or treatment had been written on the consent. S2DON stated the blank consent should not have been signed by Patient #4 because someone could have filled in information about a surgery at a later date. S2DON stated pre-signing blank consents was an error.

In an interview on 3/7/13 at 8:35 a.m. with S5RN, she stated she would get patients to sign all consents on admission regardless if they were completed or not. S5RN said she realized recently that having patient ' s sign blank consents could lead to a problem. S5RN also verified she had gotten the blank consent for surgical treatment signed for Patient #4.

Patient #5

Review of the medical record for Patient #5 revealed he was a 54 year old male who had been admitted to the hospital on 1/25/13 with diagnosis which included a sacral decubitus ulcer.

Review of the document in Patient #5's medical record titled Permission for Restraint Use revealed three options were available for Patient #5 to choose regarding permission for restraint use:

1. Use safety restraints as authorized by a physician for a specified and limited period of time as necessary to protect the patient from injury to themselves or others.

2. Do Not use safety restraints in any form under any circumstance except use of side rails while in bed.

3. Do Not use safety restraints in any form, under any circumstance for the above named resident.

Further review of the Permission for Restraint Use consent form revealed none of the three choices had been chosen by Patient #5 although the document had been signed by Patient #5 and witnessed by S16RN on 1/25/13.

Review of the document in Patient #5's medical record titled Advanced Directive Acknowledgement revealed 4 choices were available for Patient #5 to initial:

1. ___ I have been given written materials about my right to accept or refuse medical treatment.

2. ___ I have been informed of my rights to formulate an Advance Directive.

3. ___ I understand that I am not required to have an Advance Directive in order to receive medical treatment at this health care facility.

4. ___ I understand that the terms of any Advance Directive that I have will be followed by (the hospital) and my care givers to the extent permitted by law.

Further review of the consent revealed two other options for Patient #5 to choose:

___ I have EXECUTED an Advance Directive.

___ I have NOT EXECUTED an Advance Directive.

None of the 4 acknowledgements of understanding or either of the choices for execution of an Advance Directive had been initialed or selected by Patient #5. Further review revealed the consent had been signed by Patient #5 and S16RN on 1/25/13.

In an interview on 3/6/13 at 2:30 p.m. with S2DON, she verified the consents for Patient #5's options for Advance Directives and restraint usage had been signed by Patient #5 and witnessed by S16RN, but had not been completed. S2DON stated the forms should not have been signed by Patient #5 and witnessed by S16RN until the choices in the consents were selected because they could have been filled out at a later date.

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the facility on 1/29/13 with diagnosis which included a wound on the left foot, diabetes, and renal failure.

Review of the document in Patient #10's medical record titled Permission for Restraint Use revealed three options were available for Patient #10 to choose regarding permission for restraint use:

1. Use safety restraints as authorized by a physician for a specified and limited period of time as necessary to protect the patient from injury to themselves or others.

2. Do Not use safety restraints in any form under any circumstance except use of side rails while in bed.

3. Do Not use safety restraints in any form, under any circumstance for the above named resident.

Further review of the Permission for Restraint Use consent form revealed none of the three choices had been chosen by Patient #10 although the document had been signed by Patient #10 and witnessed by S5RN on 1/29/13.

In an interview on 3/7/13 at 8:40 a.m. with S5RN, she verified she had gotten Patient #10 to sign the Permission for Restraint consent without having the patient select one of the three options available and that it was incorrect.

Patient #17

Medical record review revealed Patient #17 was a 53 year old male who had been admitted to the hospital on 11/30/12 for post right below the knee amputation following gangrene.

Review of the document in Patient #17's medical record titled Permission for Restraint Use revealed three options were available for Patient #17 to choose regarding permission for restraint use:

1. Use safety restraints as authorized by a physician for a specified and limited period of time as necessary to protect the patient from injury to themselves or others.

2. Do Not use safety restraints in any form under any circumstance except use of side rails while in bed.

3. Do Not use safety restraints in any form, under any circumstance for the above named resident.

Further review of the Permission for Restraint Use consent form revealed none of the three choices had been chosen by Patient #17 although the document had been signed by Patient #17 and witnessed (unable to read name) on 11/30/12.

In an interview on 3/6/13 at 3:15 p.m. with S2DON, she stated the Permission for Restraint form for Patient #17 should have not been signed by the patient and witnessed by a staff member without an option for treatment having been chosen because anyone could come pick one of the 3 choices later without the patient's knowledge.






31048


Patient #2

Medical record review revealed Patient #2 was admitted to the hospital on 03/01/13 with diagnoses which included Scrotal Abscess, Urinary Tract Infection, MRSA and Paraplegia. Patient #2 was admitted for wound care and intravenous antibiotic therapy.

Review of the document in Patient #2's medical record titled Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information revealed none of the information had been written in the following blanks: Description, nature of the treatment/procedure; Purpose, Patient Condition; Material risks of treatment procedure; Therapeutic alternatives, risks associated therewith, and risks of no treatment; Name of authorized physician or group.

Further review revealed the document had the following statements listed:

I have read and understand all information set forth in this document and all blanks were filled in prior to signing. This authorization for and consent to medical treatment or surgical procedure is and shall be valid until revoked.

I acknowledge that I have had the opportunity to ask any questions about the contemplated medical procedure or surgical procedure described in item 2 of this consent form, including risk and alternatives, and acknowledge that my questions have been answered to my satisfaction.

Further review of the Patient Consent to Medical or Surgical Procedure and Acknowledgement or Receipt of Medical Information document revealed it had been signed by Patient #2. The consent was dated 03/01/13.

In an interview on 03/05/13 at 3:50 p.m. with S2DON, she verified a surgical consent for Patient #2 had been signed by Patient #2 although no information about a specific surgical procedure or treatment had been written on the consent. S2DON stated the blank consent should not have been signed by Patient #2 and that the consents should not be signed prior to the time of the procedure.

Patient #13

Medical record review revealed Patient #13 was a male admitted to the hospital on 02/06/13 with a diagnoses of infected decubitus ulcer and paraplegia. Patient #13 was admitted for would care and intravenous antibiotics.

Review of the document in Patient #13's medical record titled Patient Consent to Medical Treatment or Surgical Procedure and Acknowledgement of Receipt of Medical Information revealed none of the information had been written in the following blanks: Description, nature of the treatment/procedure; Purpose, Patient Condition; Material risks of treatment procedure; Therapeutic alternatives, risks associated therewith, and risks of no treatment; Name of authorized physician or group.

Further review revealed the document had the following statements listed:

I have read and understand all information set forth in this document and all blanks were filled in prior to signing. This authorization for and consent to medical treatment or surgical procedure is and shall be valid until revoked.

I acknowledge that I have had the opportunity to ask any questions about the contemplated medical procedure or surgical procedure described in item 2 of this consent form, including risk and alternatives, and acknowledge that my questions have been answered to my satisfaction.

Further review of the Patient Consent to Medical or Surgical Procedure and Acknowledgement or Receipt of Medical Information document revealed it had been signed by Patient #13. The consent was dated 02/06/13.

In an interview on 03/06/13 at 3:30 p.m. with S2DON, she verified a surgical consent for Patient #13 had been signed by Patient #13 although no information about a specific surgical procedure or treatment had been written on the consent. S2DON stated the blank consent should not have been signed by Patient #13 and that the consents should not be signed prior to the time of the procedure.

Patient #12

Review of the medical record for Patient #12 revealed he was a female who was admitted to the hospital on 01/23/13 with a diagnosis of neurosyphilis. Patient #12 was admitted for intravenous antibiotic therapy.

Review of the document in Patient #12's medical record titled Permission for Restraint Use revealed three options were available for Patient #12 to choose regarding permission for restraint use:

1. Use safety restraints as authorized by a physician for a specified and limited period of time as necessary to protect the patient from injury to themselves or others.

2. Do Not use safety restraints in any form under any circumstance except use of side rails while in bed.

3. Do Not use safety restraints in any form, under any circumstance for the above named resident.

Further review of the Permission for Restraint Use consent form revealed none of the three choices had been chosen by Patient #12 although the document had been signed by Patient #12 and witnessed by S5RN on 1/23/13.

Review of the document in Patient #12's medical record titled Advanced Directive Acknowledgement revealed 4 choices were available for Patient #12 to initial:

1. ___ I have been given written materials about my right to accept or refuse medical treatment.

2. ___ I have been informed of my rights to formulate an Advance Directive.

3. ___ I understand that I am not required to have an Advance Directive in order to receive medical treatment at this health care facility.

4. ___ I understand that the terms of any Advance Directive that I have will be followed by (the hospital) and my care givers to the extent permitted by law.

Further review of the consent revealed two other options for Patient #12 to choose:

___ I have EXECUTED an Advance Directive.

___ I have NOT EXECUTED an Advance Directive.

None of the 4 acknowledgements of understanding or either of the choices for execution of an Advance Directive had been initialed or selected by Patient #12. Further review revealed the consent had been signed by Patient #12 and S5RN on 1/23/13.

In an interview on 3/6/13 at 3:30 p.m. with S2DON, she verified the consents for Patient #12's Permission For Restraint Use and the Advance Directive Acknowledgement form had been signed by Patient #12 and witnessed by S5RN, but had not been filled out correctly and the forms should have been completed correctly prior to obtaining any signature.

Patient #16
Medical record review for Patient #16 revealed a female was admitted to the hospital on 09/24/12 with a diagnosis of an infected hip ulcer. She was admitted to the hospital for wound care and intravenous antibiotic therapy.

Review of the document in Patient #16's medical record titled Permission for Restraint Use revealed three options were available for Patient #16 to choose regarding permission for restraint use:

1. Use safety restraints as authorized by a physician for a specified and limited period of time as necessary to protect the patient from injury to themselves or others.

2. Do Not use safety restraints in any form under any circumstance except use of side rails while in bed.

3. Do Not use safety restraints in any form, under any circumstance for the above named resident.

Further review of the Permission for Restraint Use consent form revealed none of the three choices had been chosen by Patient #16 although the document had been signed by Patient #16 and witnessed by S5RN on 09/24/12.

In a face-to-face interview on 3/7/13 at 10:30 a.m., S5RN verified that Patient #16 signed, and she witnessed, the Permission for Restraint consent form dated 09/24/12, and the patient did not select one of the three options available.

Review of the document in Patient #16's medical record titled Advanced Directive Acknowledgement revealed 4 choices were available for Patient #16 to initial:

1. ___ I have been given written materials about my right to accept or refuse medical treatment.

2. ___ I have been informed of my rights to formulate an Advance Directive.

3. ___ I understand that I am not required to have an Advance Directive in order to receive medical treatment at this health care facility.

4. ___ I understand that the terms of any Advance Directive that I have will be followed by (the hospital) and my care givers to the extent permitted by law.

None of the 4 acknowledgements of understanding of the choices for execution of an Advance Directive had been initialed or selected by Patient #16. Further review revealed the consent had been signed by Patient #16 and S5RN on 09/24/12.

In a face-to-face interview on 3/7/13 at 10:30 a.m., S5RN verified that Patient #16 signed, and she witnessed, the Advance Directive Acknowledgment form dated 09/24/12, and the patient did not select one of the three options available.

Based on interview and record review, the hospital failed to provide patient safety by not controlling drugs and biological in accordance with applicable standards of practice as evidenced by the hospital failing to ensure all non-emergent medication orders were reviewed for appropriateness by a pharmacist before the first dose was dispensed.
Findings:
Review of the Contracted Pharmacy "A" Policy 3.02C titled Medication Interaction/Contraindication, revised 4/30/12, revealed in part:

1. Necessary/required medication orders: the facility staff will contact the pharmacist on-call by phone to inform of necessary/required new order and fax order to the pharmacy.

2. The Pharmacist will require the patient's allergies, medication profile, indications for use of ordered necessary/required medications to perform the medication interactions/contraindications of all medication orders and inform facility staff of clearance for use.

In an interview on 3/5/13 at 11:45 a.m. with S3RN, he stated when the physician wrote a new medication order or admission medication orders for a patient, the staff would administer the medications to the patient if they were due and were in the hospital stock medications. S3RN stated the nurses did not wait for the pharmacist to review the medications for appropriateness before they were administered to the patients. S3RN also stated the hospital had no policy to wait for approval from the pharmacy before first dose medications were administered to the patients.

In an interview on 3/5/13 at 1:45 p.m. with S2DON, she stated when orders for new medications for a patient were received from the physician, the staff administered the medications if they were in stock at the hospital before they were approved for appropriateness by a pharmacist.

In an interview on 3/6/13 at 9:20 a.m. with S14Pharmacy Director, he stated when orders for new medications were faxed to the pharmacy, they were reviewed by the pharmacist for appropriateness. S14Pharmacy Director stated the hospital was not notified by phone if a patient's orders were appropriate, but the medications were placed on a printed MAR (Medication Administration Record) and sent to the hospital after being checked. He said once the hospital received the printed MAR, the nurses knew the orders had been checked by the pharmacist. When asked if the staff at the hospital ever wrote new medications on a patient's MAR and administered the medications before receiving the printed MAR from the pharmacy, S14Pharmacy Director stated they did. When asked how the staff would know if the hand written medications had been reviewed by a pharmacist before administering the medications, he stated he was not really sure.

Based on record review and staff interview, the hospital failed to ensure the Utilization Review (UR) Committee consisted of at least two doctors of medicine or osteopathy. Findings:

Review of the hospital's Utilization Management Plan dated 06/14/08, and provided as current by S1 Assistant Administrator, revealed in part the following: Members:

The Utilization Review Committed members include no less than two (2) doctors of medicine, who are not professionally involved or has financial interest in the care of the patient whose case is being reviewed, and the Quality Improvement Director. 2 Medical physicians will serve as co-chairs of the Utilization Management Committee.... There was no documented evidence of who the members of the committee were.

Review of the last documented UR Meeting dated 10/24/12 revealed the meeting was attended by S1 Assistant Administrator and S18UR (Former UR Coordinator) only.

In a face-to-face interview on 03/07/13 at 3:30 p.m., S1 Assistant Administrator stated the current members of the UR committee were S10 Physician, "a clinical nurse", and herself. S1 Assistant Administrator stated there was no UR Coordinator. She stated the nurse that was the UR Coordinator was ill and resigned several months ago. When asked who the clinical nurse was, she stated, "Just one of the nurses on duty." S1 Assistant Administrator verified there was only one physician on the committee.

Based on record review and staff interview, the hospital failed to ensure the UR Plan was implemented as evidenced by failing to review all admissions, failing to document any UR reviews since June 2012, and failing to conduct UR meetings.

Findings:

Review of the hospital's Utilization Management Plan dated 06/14/08, and provided as current by S1 Assistant Administrator, revealed in part the following:

Meetings: The Utilization Management Committee will meet at least 4 times a year, but may meet more frequently if needed. Scope of Responsibility: The Utilization Review Committee shall review all admissions to the hospital before, at or after the hospital admission. The focus of the review shall include but is not limited to the following: Admissions, duration of stay, professional services furnished...

Review of the last documented UR Meeting dated 10/24/12 revealed the meeting was attended by S1 Assistant Administrator and S18UR (Former UR Coordinator) only. The minutes revealed the following: "Facility is in full swing of new Medicaid high cost. All admission are medically necessary determinations are done by the doctors. Continued stay review is done by Medical Director on a one on one basis. Patients are educated to their care. Staff is trained as changes present themselves. Wound care is at its highest evaluation of clinical practices. Care plan meetings are up-to-date and ongoing. Medication cost still rising but Medicaid monies are cut for 2012 and 2013." There was no documented evidence of any UR meetings since 10/24/12.

Review of the UR Record Review Worksheets revealed that there was no documented evidence of medical record reviews done since June 2012.

Review of the medical record for Patient #3 revealed the patient was admitted to the hospital in July 2012 with diagnosis of Decubitus Ulcers and was still a current inpatient (8 month stay). There was no documented evidence of a UR record review for Patient #3.

In a face-to-face interview on 03/07/13 at 3:30 p.m., S1 Assistant Administrator stated the current members of the UR committee were S10 Physician, "a clinical nurse", and herself. S1 Assistant Administrator stated there was no UR Coordinator. She stated the nurse that was the UR Coordinator was ill and resigned several months ago and verified S18UR was the former UR Coordinator. S1 Assistant Administrator verified Patient #3 had been an inpatient for 8 months, and was unable to provide documentation of a UR record review. S1 Assistant Administrator was unable to provided any UR record reviews done since June 2012 and was unable to provide any meeting minutes since 10/24/12.

Based on observations and interviews, the hospital failed to maintain an acceptable level of safety and quality of the facility, supplies, and equipment as evidenced by outdated medical supplies in the clean supply room with current medical supplies.

Findings:

An observation was made 3/5/13 at 10:50 a.m. to 11:20 a.m. with S17Supply Manager in the medical supply room. Intermingled with current dated supplies were the following outdated supplies, in part:

2- packages of Silk Suture (expiration date of 3/11)

2 10 ml syringes, each with a capped 22 gauge 1 inch needle unwrapped

1- 3 ml (milliliter) vial of Normal Saline for respiratory use ( expiration date 10/12).

3- 3 ml vials of Albuterol Bromide Inhalation Solution (medication used in respiratory treatments) ( expiration date 11/12)

1-3 ml vial Albuterol Sulfate Solution (mediation used in respiratory treatments).

40- Urinary Catheter kits (expired 10/12)

53- Single sterile glove packages (expiration date of 12/07).

1-Kerlix Antimicrobial Super Sponge 6 inches by 6.75 inches ( expiration date of 7/1/1)

2 of 4- Coude Taper Tip (Urinary) Catheter 12 French 16 " (expiration date of 5/12)

40- 750 ml Drainage bag with Y-Adapter (Urinary Collection Bag) (expiration date of 4/12)

7 - Respiratory Suction Catheter Kits-Sterile (expiration date of 11/12)

16 of 23 boxes of Bardex Urinary Catheters-sterile. ( expiration dates were : 3 boxes-4/11,
7 boxes-7/11, 3 boxes-2/12, 1 box-4/12, and 2 boxes-10/12)

Further observation revealed dust under shelving units and in the corners of the room. An area of light caramel color substance was noted on the floor next to the shelving units.

In an interview 3/5/13 at 11:20 a.m. the above findings were verified by S17Supply Manager, S3RN (Registered Nurse), and S2DON (Director of Nursing).

Based on record review and interview the hospital failed to implement a system that included identifying, reporting, investigating, and controlling infections and communicable diseases as evidenced by:

1) failing to maintain a sanitary physical environment;

2) failing to ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians and APRNs (Advance Practice Registered Nurse) credentialed at the hospital were screened annually for TB (Tuberculosis) for 5 of 5 (S9Physician, S10Physician, S13Physician, S11FNP, S12APRN) credentialed files reviewed out of a total of 5 credentialed physicians and APRNs on staff at the hospital; and

3) no documentation for an infection control program that included investigation and a plan for the prevention of infections.

Findings:

1) failing to maintain a sanitary physical environment:

A review was made of the infection Control Policy and Procedure for EVS, Policy:IC-XIII. The policy was presented by the hospital as current and said in part:

Policy: Proper cleaning of the environment is an essential component for preventing and controlling infections. All work places, passageways, storage rooms, and service rooms will be kept clean, orderly, and in sanitary condition. Although housekeeping is generally responsible for cleaning, it is the responsibility of all staff to assist in daily upkeep.

A review was made of the infection control policy titled EVS-Housekeeping, Policy: IC-XIII-A. The policy was presented by the hospital as current and said in part:

III. Housekeeping will remove (when possible) and/or report to the appropriate department when noting broken furniture ...

IV. All areas of the hospital will be cleaned daily and as needed.
a. Floors will be swept and mopped daily and prn using an EPA approved disinfectant ...Nursing staff will clean and maintain all medical machines and equipment.

11. Storage Rooms- Floors will be swept and mopped daily and prn using an EPA approved disinfectant. Counter-tops and surfaces will be wiped down daily with an EPA approved disinfectant.

14. Physical Therapy- Floors will be swept and mopped daily and prn using an EPA approved disinfectant. Counter-tops and surfaces will be wiped down daily with an EPA approved disinfectant.

A review was made of the infection control policy titled EVS-Equipment Cleaning and Storage, Policy:IC-XIII-B. The policy was presented by the hospital as current and said in part:

2. Soiled or used equipment will be cleaned in patient's room, then removed from the room and wiped down again with an EPA or manufacturer ' s approved disinfectant, following the instructions on the disinfectant/cleaning agents' label. Than the disinfected equipment will be covered with a clear plastic bag and stored in the clean storage area or its designated storage area.



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A facility tour conducted on 3/5/13 from 10:10 a.m. until 10:35 a.m. with S1Assistant Administrator who verified the following observations:

3 patient hallways- Dust, paper, and various debris in inner pocket of the handrails in the hallways.


Therapy room- 3 used buffer pads were stacked on the sink. No paper towels were near the sink or in the room. Equipment used for general population of the Hospital was stored in therapy room which included a bed scale, 17 walkers, 2 wheelchairs, a bedside commode, a chair scale, and two oxygen tanks. In an interview on 3/5/13 at 10:20 a.m., S1Assistant Administrator stated the equipment should not have been stored in the therapy room.

Nourishment Room- On top of patient nourishment refrigerator was a Tupperware container with a brown substance inside, approximately 50 salt packages, and a layer of dust.

Room 100- The seat cushion in the bedside chair had a missing section of vinyl approximately 8 inches long by 4 inches wide.

Room 105- The wallpaper on one wall was torn approximately 4 inches, still attached to, and pulled away from the wall. Brown dried residue was observed around the base board. Splatters of dried translucent light brown substance were noted on the wall by the head of the bed. The blinds were observed to have a brown dried substance in a splatter pattern. The blinds were noted to be rusted along the bottom rail. A latex glove, partially turned inside out was observed on top of a sharps box holder. In an interview with S1Assistant Administrator 3/5/13 at 10:15 a.m. S1Assistant Administrator identified the glove as dirty and stated it should not have been left there. The assistant administrator verified all the above noted findings.


Room 110- The pull chain for the over bed light had an extension made of a 14 inch piece of yellowed, discolored gauze tied to the pull chain. Cracks were observed in the vinyl on the armrest of a Geri-chair. The call bell had a thick layer of a brown substance coating all sides. There was an area in the middle of the floor of light brown sticky substance. The plastic cover to the air conditioner control panel was broken off the unit and sitting on the window sill; it was noted to have dust on it. The window blinds had splatter type spots of a light brownish white matter. The blinds were observed to have dust on them, and the bottom rail was rusted. In an interview 3/5/13 at 10:45 a.m. S1Assistant Administrator reported that the room should have been cleaned when the last patient was discharged. The assistant administrator verified the above observations. She then reported that the room had been cleaned when the last patient had been discharged. She reported that he last patient to use the room was discharged 3/01/13.

The following observations were made on 3/5/13 between 10:35 a.m. and 11:35 a.m. with S3RN:

Medication Room- Observation of the medication cart revealed all drawers had sections for medications that contained debris around all corners, a sticky substance in 5 of the sections, 4 loose pills, paper, 2 bottle caps, opened alcohol preps, and 3 vial caps. Observation of the medication refrigerator revealed hair and dirt on the shelves where the medication was stored and on the inside of the door.

Clean Supply Room: An area directly in front of a medical supple shelf, approximately 6 inches wide by 12 inches long, had a sticky caramel colored substance on the floor. Dust and paper refuse was noted under the shelving units that held clean medical supplies. Medical supplies with an expiration date prior to the observation date (3/5/13) included, in part, the following: In and Out Catheter Kits (40 kits), 4 vials of Albuterol (medication for prescribed respiratory treatments), 53 sterile gloves in single packs, 40 urinary drainage bags, 7 respiratory suction catheter kits, and 15 boxes of sterile urinary catheters. In an interview 3/5/13 at 11:20 a.m. the above findings were verified by S17Supply Manager, S3RN (Registered Nurse), and S2DON (Director of Nursing).

Additional Clean Supply Room- A box of adult briefs was stored on the garbage can. No paper towels were in the dispenser near the sink.

Room 111- The unoccupied room had a straw under the bed, debris in several places on the floor, cobwebs on a pole near bedside, a brown substance that had dripped down the front grate of the air conditioner, stains on the outside and inside of trash can, paper and debris on inside of unlined garbage can. In an interview on 3/5/13 at 11:30 a.m. with S3RN, he stated the room should have been cleaned after the last patient left and kept clean.

Room 113- Linens were observed in a pile at the foot of the bed. A cigarette butt was observed on the floor near the bed. The unlined trash can had brown stains on the inside and outside, a half empty saline syringe and a half empty cup of butter at the bottom of the can. In an interview on 3/5/13 at 11:35 a.m. with S3RN, he stated the room should have been cleaned after the last patient was discharged and kept clean.

In an interview on 3/5/13 at 11:38 a.m. with S7Housekeeping, she stated she cleaned the patient rooms after the patients were discharged and every couple of days. S7Housekeeping said the cleaning consisted of sweeping, mopping, dusting, and generalized cleaning of the rooms.

In an observation on 3/7/13 at 9:45 a.m. with S2DON, the following areas were the same as observed on 3/5/13: Medication room refrigerator, Room 111, and Room 113. In an interview at that time, S2DON stated the rooms were supposed to be cleaned every day and there was no excuse why they were that dirty.




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2) failing to ensure a process was in place for prevention of communicable disease by the staff as evidenced by no documented evidence the physicians and APRNs (Advance Practice Registered Nurse) credentialed at the hospital were screened annually for TB:

Review of the credentialing files for S9Physician, S10Physician, S13Physician, S11FNP, S12APRN revealed no documented evidence of the results of a TB screening since 2010.

On 03/07/13 at 3:25 p.m. S1 Assistant Administrator verified she was responsible for credentialing of physicians and APRNs. S1 Assistant Administrator reviewed the credentialing files of S9Physician, S10Physician, S13Physician, S11FNP, S12APRN and verified there were no TB screenings done since 2010.


3) no documentation for an infection control program that included investigation of and a plan for the prevention of infections.

Review of a Policy and Procedure titled Infection Control Program, Policy IC-I, revised 03/10 and provided by S8Infection Control as current revealed ,in part, the following:
Policy:...the hospital has a hospital wide Infection Control Program which is effective in surveillance, prevention, and control of infections...
Procedure: "...4. Control measures are implemented to identify, prevent, control, and manage infections and possible sources...9; Conduct annual Infection Control Program evaluation and plan to determine effectiveness and recommend improvement strategies. 10. Conduct environmental infection control and safety rounds throughout the hospital at least monthly, submit timely notices/work orders and reports."

Review of Infection Control documents revealed a hospital infection control annual summary for 2012 that documented 6 total HAI ( hospital acquired infections). 2 infections were categorized as skin/soft tissue infections, 2 were UTIs (Urinary Tract Infection), and 2 were Pneumonia. Further review revealed quarterly reports of HAI by month. The reports included the number of charts reviewed and the total patient stay days for each month. The number of HAIs identified was recorded, along with the medical record number, admit date and diagnosis for each patient identified with an HAI. The summary paragraph recounted the above information then and read, " It's imperative to culture wounds and other sites as indicated by policy, on or within 3 days of admit. Good hand hygiene is still key to patient health and safety. Infection Control in-services are conducted throughout the year." Further review revealed no documentation of any investigation into possible causative factors, or any new interventions identified to prevent new infections.

Review of an Infection Prevention and Control Inspection (Checklist) for 1/23/13 and 2/25/13 , provided by S8Infection Control revealed the following:

A list of items to be inspected were as Rooms clean-no visible dust on surfaces, nothing should be stored on floors, room doors close securely/tightly, vents are clean with no visible dust, holes, dings in the wall have been repaired, curtains/blinds on windows are clean, floors are clean, toilets flush, adequate amount of soap and paper towels at each sink, waste bins are available in all rooms, refrigerators clean/items dated, refrigerator temperature charts are up to date, sharps containers are ready for use, red hazardous waste bins are available on every unit, hazardous waste bins are located in soiled utility room and are covered appropriately, soiled linen is disposed of properly, no food items in patient rooms, showers have been activated and the shower head is in place with no visible mold, and janitor closet and trash chute area are clean.

- 1/23/13 Rooms 111-114 were listed as having been inspected for cleanliness/infection control. All items on the form were checked with a check mark, except refrigerator items marked with "N/A" (not applicable). No documentation was noted in the exception or description columns.

-2/25/13 Rooms 100, 105, Therapy : All items had a check mark with the exception of Floors are clean for 100, 105 and P.T. (Physical Therapy) , description of dirty floors, Toilets flush for 100 and 105, description of dirty bathrooms, adequate amount of soap and paper towels at each sink for P.T., description of "needs hand towels". N/A was noted for "Hazardous waste bins are located in soiled utility room and are covered appropriately"; "Showers have been activated and the shower head is in place", and "Janitor closet and trash chute area are clean".

The following observations were made 3/7/13 between 10:20 a.m. and 10:45 a.m., with S8Infection Control:

Room 100: A dried medium brown transparent area on floor under the bedside table and between the table and bed was observed. There were 3 round spots of bright red on the floor at the upper edge of the bed closest to the hallway door. Along the baseboards beside and behind the bed a thick yellowish dried substance was noted in a drip and splatter pattern on the wall beside and behind the headboard of the bed. There were 3 small pieces of paper under the bed. The cal bell hand piece was noted to be covered in a substance that was off white/slightly yellow in color, was dried, and flaking. In the bathroom there was hair and dust on the floor by the toilet. The bathroom floor had a dark brown spot approximately 1-2 cm (centimeters) in diameter. There was a roll of brown paper hand towels sitting in the windowsill of the bathroom. No paper towels were in the holder in the bathroom. In an interview 3/7/13 at 10:28 a.m. S8Infection Control stated that the spill on the floor and wall, as well as on the call bell looked like old tube feeding formula. She verified the above findings, and that she had inspected Room 100 on her environmental rounds 1/3/13 and 2/25/13.


Room 105: Splatters of dried translucent light brown substance were noted on the wall by the head of the bed. The empty sharps box holder was observed to have a thick layer of dust on it. The top of the sink containing the facet and handles, in the bathroom, was observed to have a very thick build-up of a whitish substance over half of the porcelain. Both the far wall of the bathroom and the far inside wall of the toilet had spots of light brown in a spatter pattern. The bathroom tissue (enclosed dispenser) was taped closed with a large piece of cloth medical tape. In an interview 3/7/13 at 10:26 a.m. S8Infection Control verified the above findings, and that she had inspected Room 105 on her environmental rounds 1/3/13 and 2/25/13.

Room 110- The call bell control was covered with a dried flaky substance. There was dust noted rolling on floor. In a trash can beside the patient bed was a yellow/light brown colored long strip of cotton gauze. The gauze strip was noted to be white and curved at one end, as if it had been tied in a knot. A dried light brownish white opaque substance was noted on the wall by the bed headboard in drip and splatter patterns. A band of dust was observed in one corner of the room approximately 4-5 inches long and attached to the ceiling at either end of the band. In the bathroom the toilet was noted to be dirty. A half empty roll of brown paper toweling was observed in the window sill. In an interview 3/7/13 at 10:24 a.m. S8Infection Control verified the above findings. She stated that the residue noted on the call bell handle and the wall looked like it might be old tube-feeding formula.

Patient Nourishment Room: The wall next to the garbage can had splatters of a light red substance and a medium brown substance. The top of the garbage can had part of it's hinged covers cracked and broken off. The remaining pieces of garbage top had splatters of a light red substance, medium brown substance and off-white substance. In the refrigerator identified as used for patient nourishments the following were observed: 3 plastic bags, one which contained a bowl of unidentified contents, another with unidentified contents, and one with fruit. None of the bags were labeled with a name, date, or contents. There were 2 unlabeled and dated plastic zipped containers, a package of undated Yoplait yogurt-6 oz (ounces), a pint of half and half with "Mr." and a surname written on it with no date opened. The name on the half and half carton did not match any current patients, and a stamped expiration date was 12/24/12. In the door section of the refrigerator was an approximately 1/2 full 18 oz. bottle of barbeque sauce with no name or date on it. The seal around the refrigerator door had numerous pink and brown spots on it. The handle was noted to have light brown dirty marks on it. The kitchen sink was noted to have a large amount of build up of substance surrounding the facet and handle areas. In an interview 3/5/13 at 10:30 a.m. S8Infection Control verified the above findings. She stated that while she considered it OK to have staff food in the refrigerator, all food should be labeled and dated. She confirmed that the dirty areas in the refrigerator and in the kitchen were an infection control concern, and had not been identified by the herself or the hospital.

In an interview 3/7/13 at 9:50 a.m. S8Infection Control reviewed the infection control documents and confirmed that there was not an investigation of the HAIs or a plan to prevent future infections. The Infection Control Director reported that she only worked 4-6 hours a week, in the evenings. She stated that she and other staff made monthly environmental rounds on random rooms and areas, but that she did not report her findings until several weeks later when she submitted her report to the DON or Assistant Administrator. She confirmed that when she found a room or area dirty or in ill repair she did not immediately report it, or follow-up to see that corrections were made.