HospitalInspections.org

1. Based on review of nursing services and interview with staff this requirement was not fully met.

Findings:

a. In review of plan of corrections for nursing services conditions cited on November 20, 2013 (tag A 385, tag A 396) it was observed in this full survey following a complaint (April 10, 2014) that nursing care plans were still not kept current. There was no evidence that they were ongoing and if the goals identified in the nursing care plans were met or not upon discharge. There were additional nursing services deficiencies found during this full survey. See tags (A 386, A 395,A 396,A 398 and A 409) on full survey after a complaint (April 10, 2014)

b. In the plan of corrections for the nursing deficiencies cited on November 20, 2013. It stated that

"The Director of Nursing is responsible for the accuracy and completion of all nursing documentation and care plans."

c. Interview with staff was conducted at various time from April 8-10, 2014 in the administration office. See tags (A 386, A 395,A 396, A 398 and A 409) for specific dates and times of interview.


2. Based on a review of medical records, tour of the facility, policies and procedures, and staff interviews, the facility failed to ensure that nursing care was properly supervised, implemented, and evaluated; failed to ensure that an RN supervised and evaluated the care of each patient; failed to ensure that medications were secured, that glucometer controls were not expired, and that the nurse staffing plan and committee were being conducted, implemented and evaluated.

Findings included:

a. Review of medical records, tour of the facility, policies and procedures, and staff interviews revealed the director of the nursing service, responsible for the operation of the service, failed to ensure that medications were secured, that glucometer controls were not expired, and that the nurse staffing plan and committee were being conducted, implemented and evaluated. Cross refer: 482.23(a)

1. Based on observations, reviews of policies and procedures, and staff interviews the hospital failed to enforce infection control policies and procedures.

The findings included:
A. Tour of environmental services with the plant manager revealed overflowing contaminated linen receptacle with no lid.

B. tour of patients rooms revealed thru and thru holes in the base boards.

C. observation of portable X-ray unit bought into the facility - technician failed to disinfect the machine prior to entering the hospital or the patient's room (same when leaving). Hospital staff also failed to ensure technician employed hand sanitizing procedure entering or leaving the patients room.


2. Based on a review of facility policies and procedures, facility documents, personnel records, tour of the facility, and staff interviews, the facility failed to ensure there was a trained and qualified director of infection control, failed to ensure there was an active program to prevent, control and investigate infections and communicable diseases, as the Infection Control Plan and Surveillance were not being implemented, and there were findings on the patient unit which presented a risk for cross contamination.

Findings included:

A. During a tour of the facility the morning of 4/8/14 accompanied by Staff # 3, Nursing Day Shift Supervisor, the following was observed:
· There were 7 tiger top lab tubes in a cabinet in the nutrition room which expired 1/14.
· There were 4 used glucometer cases stored in the same cabinet with the tube feeding formula and the food thickener, Thickit, which were available for patient use. This presents a risk of cross contamination with the storage of potentially contaminated medical equipment with patient nutrition supplies.
· The second floor patient nourishment freezer log for April 2014 in the Therapy anteroom revealed instructions stating, "Monitoring Frequency: Twice Daily (Once per shift) **D= 7A-7P N= 7P-7A ...Instructions 1. Maintain temperature between -0.4 and -10 F. 2. Enter your initials in the box that corresponds with the temp reading for that shift." For the first eight days of April, 2014, there was no temperature documented for the following four shifts: 4/2/14 day shift and night shift; 4/2/14 night shift; 4/7/14 night shift. This presents a risk for food items to be compromised if they are maintained at temperatures which are out of range per the manufacturer.
· There was 1 tiger top lab tube in a cabinet in the Nurse Station A which expired 1/14.
· There was a 1 inch by 2 inch chip, exposing the particle board in the laminate counter top in Nurse Station A; this chip in the laminate prevented effective disinfection of the countertop in the nurse station.
· There were three bottles of glucose control solution which were not labeled with the date opened in Nurse Station C.
· In the "Dialysis Storeroom" across from patient room #222, there was a bath towel on the bottom of a wire shelving unit which was dirty with black debris and had rust-colored stains in the areas of the shelving wire. There was a paper bag containing cotton balls which was opened and the cotton balls were exposed; this presents a risk for cross-contamination with the exposed cotton balls.
· There was no temperature log for the lab storage refrigerator, in which patient specimens were stored. It could not be determined if the refrigerator was maintaining the correct temperature for the patient laboratory specimens.
· There was a sign at the entrance of each patient room which stated, "Foam In Foam Out." At 1220 on 4/8/14, Staff #4, RN responded to a call light in a patient room and entered the room without using the alcohol based hand rub. Approximately 60 seconds after entering the patient room, Staff #4 exited the room and walked down the hall into the nurses station. Staff #4 did not use alcohol based hand rub upon entering or exiting the room. In an interview with Staff #3, Shift Supervisor, at approximately 1220 on 4/8/14 in the patient care hallway stated that "Foam In Foam Out" means that staff will use alcohol based hand rub (foam) upon entering and exiting any patient room. Staff #3 confirmed that Staff #4 entered and exited the patient room without using alcohol based hand rub as required by the "Foam In Foam Out" signage and facility process.

B. The above findings were confirmed with Staff #3, Day Shift Supervisor, during the tour of the facility the morning of 4/8/14.


C. Review of the Rehabilitation Hospital Manual Policy Name: Infection Prevention and Control Plan, Policy RH-IC-114, last revised 12/1/13, stated, in part, "The Rehabilitation Hospital has developed a comprehensive approach to the significant Infection Control issues facing healthcare ...This plan provides the platform for compliance with local and national standards and is consistent with all evidence-based guidelines and where applicable, consensus statements and community standards ...Infection control is integrated into the hospital's Quality Assessment and Improvement efforts ...This plan is to be evaluated formally on an annual basis (see RH-IC-108 for annual risk assessment, as well as annual program and surveillance plan evaluation). This evaluation is reviewed by appropriate committees (see committee structure). This hospital is committed to have adequate experts to guide and monitor the IC activities, outcomes, and practices ...
Scope of Plan: This plan through policies, procedures, outcome assessment and reporting will cover the following areas:
Risk assessment and program evaluation
Readiness: Bio-terrorism, Pandemic Influenza ...
Education related to relevant areas ...
Infection Prevention and Control Program Goals: The goals of the program are evaluated at least annually and whenever there is a change in services or identified risks for patients, visitors and staff. The goals include but are not limited to:
Addressing prioritized risks for individual facilities ...
Annual goals based on infection control risk assessment."

D. Review of facility policy, "Divisional Risk Assessment" Policy number RH-IC-108, last revised 12/1/2013, stated, in part,
"The Infection Prevention and Control Risk Assessment is completed at least annually and each time there is a significant change in services or facility with input from infection control, medical staff, nursing, plant operations/Safety Officer and leadership. The assessment is completed with the annual evaluation of the Infection Prevention and Control Plan to assure the risks are identified, and prioritized with strategies developed in the planning process for the upcoming year to mitigate those risks."

E. Review of the Rehabilitation Hospital Manual Policy Name: Infection Prevention and Control Plan, Policy RH-IC-114, last revised 12/1/13, stated, in part, "Responsibilities of Infection Control Professional ...
A. Surveillance
1. Implements surveillance system as defined in plan.
2. Uses CDC criteria and standard tools for determining infection-colonization
3. Tracks, trends, analyze and reports data to IC Committee ...
B. Prevention Practices ...
5. Teaches staff, patients, families, visitors, students appropriate IC practices.
6. Implements all plans as described in the IC program.
C. Outbreak Management ...
3. In touch with important IC community trends ...
G. Performs annual and prn risk assessment
H. Performs annual IC Program evaluation ...
K. Remains current in knowledge and skills."

F. Review of the "Rehabilitation Hospital Manual Infection Control Surveillance Plan " Policy Number RH-IC-122, last revised, 12/1/13, stated, in part, "Surveillance is defined as 'a systematic method of collecting, consolidating, and analyzing data concerning the distribution and determinates of a given disease or event, followed by a dissemination of that information to those who can improve the outcomes' (APIC) ...The goals of The Rehabilitation Hospital Surveillance Program include: ...
Provide data for meaningful annual risk assessment
Compare data against Internal and External Benchmarks
Identification of opportunities to improve processes and outcomes ...
Concurrent reviews:
Compliance with Isolation Precautions"

G. An interview was conducted at 9:35 am on 4/9/14 with the Infection Control Director, Staff #2 in his office. When asked by the surveyors what training or qualifications he held in Infection Control, Staff #2 replied, "None. I haven't received any specialized training for the Infection Control Program." Staff #2 confirmed in an interview that he had no specialized training or qualifications in Infection Control.

H. Review of the Personnel folder for Staff #2 in the facility conference room revealed no documented evidence of specialized training of qualifications in Infection Control.

A second interview was conducted at 2:00 pm on 4/9/14 with Staff #2, the Infection Control Director, in his office to review the facility Infection Control Plan and facility surveillance. During the interview, Staff #2 stated that the Infection Control Plan had not been reviewed on an annual basis. Staff #2 provided no documented evidence of an annual review of the Infection Control Plan. During the interview, Staff #2 was asked about conducting an infection control risk assessment or program evaluation. Staff #2 stated that a risk assessment and program evaluation had not been conducted. Staff #2 provided no documented evidence of an infection control risk assessment or program evaluation, no policies, procedures, outcome assessment or reporting of readiness for Bio-terrorism and Pandemic Influenza. Staff #2, he stated that the goals of the infection control program had not been evaluated; Staff #2 provided no documented evidence of an evaluation of the infection control program goals.

During the second interview was conducted at 2:00 pm on 4/9/14 with Staff #2, the Infection Control Director, in his office to review the facility Infection Control Plan, Staff #2 provided the surveyors with a blank paper form entitled, "Infection Control Daily Rounds." Review of the "Infection Control Daily Rounds" paper form provided by Staff #2 revealed a tool for use in Nursing Services, Dietary Services, and Housekeeping Services to assess compliance with specific indicators, recommend corrective action, document corrective action taken, date completed, and comments. The paper form provided to the surveyor was blank, with no data written on the form. When asked, Staff #2 stated he did not conduct Infection Control Rounds because he "did not have enough time." Staff #2 provided no documented evidence to the surveyors of Infection Control Rounds that had been conducted.

When asked by the surveyors during the second interview about surveillance activities, including tracking, trending, analyzing and reporting patient data, Staff #2 stated, "I'm not doing anything with the data right now. It's there if I need it ...We haven't had any problems ...I haven't trended the tracking information. I don't have time to do that ...My boss said the Infection Control Program was 20% of my job. He said I don't have to worry about it."

When asked during the second interview if facility staff were provided Infection Control training, Staff #2 stated that staff were provided training in Infection Control at orientation and they have annual computer based training and stated that if he saw someone doing something when he was in the patient unit, he would "address it", but that "we don't have any formal education for infection control."

The above findings were confirmed in an interview the afternoon of 4/9/14 in the office of the Infection Control Director.

Based on review of medical records, tour of the facility, policies and procedures, and staff interviews, the director of the nursing service, responsible for the operation of the service, failed to ensure that medications were secured, that glucometer controls were not expired, and that the nurse staffing plan and committee were being conducted, implemented and evaluated.

Findings included:

a. During the tour of the second floor patient unit the morning of 4/8/14, accompanied by Staff #3, Day Shift Supervisor, a medication cart was observed in the patient hallway unattended. The surveyor was able to open six drawers on the unattended medication cart which contained patient medications and other drawers on the unattended medication cart containing patient medication supplies. In an interview with the Staff #3, he confirmed that the medication cart was unattended and unlocked and that patient medications were not secured and stated that the medication cart should not have been left unlocked and unattended with unsecured medications. Staff #4, an RN, then walked up to the unsecured medication cart and, when asked, confirmed that he had left the medication cart and patient medications unsecured.

b. Review of the facility policy, "Automated Drug Cabinetry", Policy A06-P, last revised 1/2013, stated in part, "Purpose: To ensure the safe, secure, and effective storage and distribution of pharmaceuticals using automated dispensing cabinetry (ADC)."

During a tour of the second floor patient unit the morning of 4/8/14, accompanied by Staff #3, Day Shift Supervisor, the following was observed:
· Two bottles of opened glucose control solution in the glucometer case with the glucometer which were not labeled with the date opened in Nurse Station A.
· Three bottles of opened glucose control solution in the glucometer case with the glucometer which were not labeled with the date opened in Nurse Station C.
There was no way to determine when the solution had been opened or to determine if the solution had been opened more than 90 days, which could affect the accuracy of the control results.

c. Review of facility policy, "Glucose Monitoring Quality Control" Policy Number RH-NU-134, last revised 12/3/13, stated, in part, "Quality Control (QC) testing using both high and low control solutions will be performed on each PCx Glucose Monitoring Device once per each calendar day that the meter is used for patient testing." Review of the document entitled, "Important Information about MediSense Control Solutions" provided to the surveyor on 4/8/14 about Glucometer Control Solutions stated, in part, "The shelf life (100 weeks) and life after first opening (90 days) will remain unchanged."

The above findings were confirmed in an interview with Staff #3, Day Shift Supervisor during the tour the morning of 4/8/14.


d. Review of the Nurse Staffing Committee meeting minutes provided to the surveyor by Staff #6 on 4/9/14 in the facility conference room revealed the following:

Minutes dated December 1, 2011 stated, in part,
"Conclusions ...
5. The Committee will meet at least quarterly ...
8. The Committee will identify the nurse-sensitive outcome measures it will use to evaluate the effectiveness of the hospital's nurse staffing plan ...
10. The Committee will evaluate the official nurse staffing plan at least semi annually by considering patient needs, nursing-sensitive quality indicators, nurse satisfaction measures collected by the hospital, and evidence based nurse staffing standards ...
The Committee will evaluate variations between the official plan and actual staffing."

e. Review of the Nursing Staffing Committee meeting minutes provided to the surveyor by Staff #6 on 4/8/14 in the facility conference room revealed the following:

Minutes dated March 27, 2013, stated, in part,
"Staffing committee meeting ...
Open positions discussed. 1. Day shift nursing supervisor
2. 2 day shift RN
3. 1 day shift CNA
4. 1 Night shift RN

Discussion was held on how to improve staffing with in-house employees ..." Five recommendations were identified in the minutes. There was no documented evidence in the minutes provided to the surveyor of which nurse-sensitive outcome measures would be used to evaluate the effectiveness of the hospital's nurse staffing plan, no documented evidence of an evaluation of the official nurse staffing plan, considering patient needs, nursing-sensitive quality indicators, nurse satisfaction measures collected by the hospital, evidence based nurse staffing standards, and there was no evaluation of variations between the official plan and actual staffing. There were no further Nursing Staffing Committee meeting minutes provided to the surveyors.

f. Review of the facility policy provided to the surveyor the afternoon of 4/8/14 entitled, "Nurse Staffing Plan" Policy Number RH-HR-120, last revised 1/31/12, stated, in part, "The purpose of this policy is to establish an overall plan for the provision of patient care by nurses and rehabilitation assistants in response to patient census and acuity ...2. Nursing staffing is a dynamic process to assure proper staffing levels to provide for quality patient care. A nursing acuity system assists in determining the required and actual nursing staffing standard. However, this is optimal staffing, and does not equate with minimum safe staffing that are (sic) established in accordance with State Law for hospital staffing." There was no documented evidence in the staffing plan of nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions; operational outcomes, such as, work-related injury or illness, vacancy and turnover rates, nursing care hours per patient day, on-call use, or overtime rates; and substantiated patient complaints related to staffing levels being considered as part of the nurse staffing plan.

g. Review of 25 Texas Administrative Code, 133.41(o) Nursing services, stated in part,"The hospital shall have an organized nursing service that provides 24-hour nursing services as needed.(1) Organization. The hospital shall have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. ...(F) The hospital shall establish a nurse staffing committee as a standing committee of the hospital. The committee shall be established in accordance with Health and Safety Code (HSC), §§161.031 - 161.033, to be responsible for soliciting and receiving input from nurses on the development, ongoing monitoring, and evaluation of the staffing plan ...(iv) The responsibilities of the committee shall be to: ...(III) identify the nurse-sensitive outcome measures the committee will use to evaluate the effectiveness of the official nurse services staffing plan;(IV) evaluate, at least semiannually, the effectiveness of the official nurse services staffing plan and variations between the plan and the actual staffing; ...(G) The hospital shall adopt, implement and enforce a written official nurse services staffing plan ....(i) The official nurse services staffing plan and policies shall:(I) require significant consideration to be given to the nurse staffing plan recommended by the hospital's nurse staffing committee and the committee's evaluation of any existing plan; ...(ii) The plan shall: ...(VI) include a mechanism for evaluating the effectiveness of the official nurse services staffing plan based on patient needs, nursing sensitive quality indicators, nurse satisfaction measures collected by the hospital and evidence based nurse staffing standards. At least one from each of the following three types of outcomes shall be correlated to the adequacy of staffing:(-a-) nurse-sensitive patient outcomes selected by the nurse staffing committee, such as, patient falls, adverse drug events, injuries to patients, skin breakdown, pneumonia, infection rates, upper gastrointestinal bleeding, shock, cardiac arrest, length of stay, or patient readmissions;(-b-) operational outcomes, such as, work-related injury or illness, vacancy and turnover rates, nursing care hours per patient day, on-call use, or overtime rates; and(-c-) substantiated patient complaints related to staffing levels; ...(iv) There shall be a semiannual evaluation by the staffing committee of the effectiveness of the official nurse services staffing plan and variations between the staffing plan and actual staffing. The evaluation shall consider the outcomes and nursing-sensitive indicators as set out in clause (ii)(VI) of this subparagraph, patient needs, nurse satisfaction measures collected by the hospital, and evidence based nurse staffing standards. This evaluation shall be documented in the minutes of the committee established under subparagraph (F) of this paragraph and presented to the hospital's governing body ...."
The above findings were confirmed in an interview with Staff #6 in an interview the afternoon of 4/8/14 in the facility conference room.

Based on review of medical records, policy and procedures, and staff interview the facility failed to ensure that a registered nurse supervise the care of patients assigned to licensed vocational nurses. The registered nurse failed to assess out of range vitals on a patient assigned to a licensed vocational nurse prior to the patient becoming unresponsive.

Findings included:

1. Review of medical records on 4/10/14 for patient # 16 revealed the following documentation by staff LVN:

a. 1/19/14 at 0715 a.m. pulse rate 111.

b. 1/19/14 at 4:09 p.m. staff LVN documented the following statements: "at 12:40 p.m. son here states patient doesn't look good. Patient noted sitting up in wheel chair. C/O diaphoresis, SOB, and chest pain. RN supervisor notified. VS 66/42 pulse 79. Progressed to Code Blue. 13:23 time of death called by MD".

c. No documentation found that the Registered Nurse was notified or addressed the tachycardia 5 hours prior to the code. No documentation that the Registered Nurse documented the events of the code in the medical records. All documentation found was completed by the Licensed Vocational Nurse.

2. Review of three patients (# 17, #18, and # 19) on 4/10/14 for date 4/4/14 revealed there was no day shift documentation for patient assessment or patient intervention by a Registered Nurse.

3. Review of facility Nursing Supervisor's position description revised 11/20/09 stated:

Assures that all staff are accountable for documenting care provided, monitors productivity of all staff and makes suggestions for prioritizing and delegating to enhance patient care.

4. Review of Texas Board of Nursing position statement 15.27 titled The License Vocational Nurse Scope of Practice states:

A LVN provides direct patient care and functions as a part of the nursing team under the direction of a Registered Nurse. The delegation of tasks or functions to the LVN is prerogative of the RN within the scope of the State Nurse Practice Act. Participates in data gathering and history taking as a component of the overall Interdisciplinary Assessment Admission that is performed by the RN. Reports to the RN all pertinent information regarding changes in the patient's medical status and requests assistance in nursing measures beyond the scope of the individuals competencies.

5. Interview conducted with S6 acting CNO after her on review of the findings confirmed the above. S6 stated that the the facilities understanding of a registered nurse's assessment requirements were only required at time of patient admission and at time of initiation of the Plan of Care. S6 confirmed that when patients' are assigned primary care under an LVN an RN does not routinely perform an assessment. S6 could not produce evidence that patient's assigned to an LVN had RN supervision.

1. Based on review of medical records and interviews with staff. The facility does not ensure the nursing care plans for each patient are kept current and upon discharge identifies if the nursing care plans goals were or were not met.

Findings:

a. Upon review of 20 (MR# 8-14, 16-21 and 26-31) closed medical records it was observed that all closed medical records reviewed had incomplete nursing care plans that had initiated goals per patient but there was no indication upon discharge of the patient if any of the initiated goals in the nursing care plans were kept current or if they were met or not met.

Example 1: pt. #14, 23y/o male. Admitted 01/14/14, Discharged: 02/06/14, length of stay 23 days. Has 12 separate medical problems with goals and interventions identified and initiated in the nursing care plan on date of admittance 01/14/14. Of these 12 identified medical problems 10 out of 12 of these problems there were no indications if these goals changed during hospitalization. There is no indication during the hospital stay and after discharge if any of these 12 separate medical problems goals were met or not.

Example #2: pt. #26, 72y/o female. Admitted: 01/31/14, Discharged: 02/08/1, length of stay 8 days. Has 5 separate medical problems with goals and interventions identified and initiated in the nursing care plan on date of admittance 02/01/14. There is no documentation in the nursing care plan demonstrating if these goals change during the course of hospitalization. There is no indication during the hospital stay and after discharge if any of these 5 separate medical problems goals were met or not.

Example #3, pt. # 27, 60 y/o male Admitted 12/18/13, Discharged: 01/02/14, length of stay: 15. Has 5 separate medical problems with goals and interventions identified and initiated in the nursing care plans on December 19, 2013. There is no documentation in the nursing care plan demonstrating if these goals change during the course of hospitalization. There is no indication during the hospital stay and after discharge if any of these 5 separate medical problems goals were met or not.


b. Interviewed staff #9, RN at 3:23pm on April 09, 2014 in the administration boardroom. Staff # 9, RN who reviewed the nursing care plans selected and was unable to located and show evidence in the electronic medical record that the nursing care plans in the closed medical records of inpatients were kept current and could show no evidence if the goals of the initiated care plans were met or not met.


2. Based on review of medical records, policy and procedures, and staff interview, the facility failed to ensure that the nursing care plan was kept current by failing to update or revise the plan of care for patient # 15 who experienced a significant change in condition on 3/29/14 and 4/03/14.

Findings included:

1. Review of medical records on Patient #15 admitted on 3/14/14 with the Chief Complaint of "Decline in function following bilateral below-knee amputations revealed the following:

a. Past Medical/Surgical History: Stage IV pressure ulcer at the sacrum, Diabetes Type II, End Stage Renal Disease on hemodialysis, Anemia, Peripheral vascular disease

b. Review of Nursing Notes revealed the following:

On 3/29/14 documentation revealed the patient was having small amounts of continuous bleeding from the AV graft site to left upper arm. Patient to be transferred to the emergency room

On 4/2/14 documenation revealed Lab Test Hemoglobin/hematocrit 7.5/23.1

On 4/3/14 documentation revealed a consent signed by patient for one unit of packed red blood cell.

c. Review of the patient's current care plan (including review of all diagnosis) revealed there was no documentation that the patient's care plan was updated or revised to address the patient's past medical history of Diabetes, End Stage Renal Disease on hemodialysis, bleeding of access, and or the anemia.

2. Review of policy and procedures titled Nursing Plan of Care revised on 1/13/12 stated:

The nursing care is directed towards illness prevention, and resolution of health problems. Established standards of nursing care are used to guide practice as well as benchmark clinical practice on a continuing basis.

3. An interview conducted with the Supervising Nurse (S3) on 4/09/14 following his own review of the findings revealed he was unaware of the discrepancies found. S3 confirmed the findings and stated that the plan of care should have been updated to capture the change in condition. At time of the interview no evidence of compliance was presented were noncompliance was found.

1. Based on review of medical records and staff interview the facility failed to adequately supervise the dialysis department staff.

The findings included:

a. Review of physician orders for dialysis for patient #15 dated 3/17/14 revealed incomplete dialysis orders with no documentation that a regi1.stered nurse clarified. The physician's orders did not state the dialyzer size or needle gauge size.

b. Review of dialysis flow sheets for patient # 15 revealed the following discrepancies:

3/17/14 - Dialysate Flow Rate (DFR) not set per physician order

3/19/14 - Flow sheet documentation for allergies stated NKDA patient is allergic to Plavix, no gastrointestinal assessment documented, no Respiratory Assessment documented, no needle gauge size documented, no LOC documented post treatment

3/21/14 - Flow sheet documentation for allergies stated NKDA patient is allergic to Plavix, and no respiratory assessment documented

3/24/14 - No respiratory assessment documented and no needle gauge size documented

4/7/14 - Flow sheet documentation for allergies stated NKDA patient is allergic to Plavix

c. Interview conducted with S9 on 4/9/14 after her own review was unaware of the discrepancies found. S9 confirmed the above findings.

1. Based on medical record review and staff interview the facility failed to initiated a blood transfusion according to facility policy and procedure. The facility also failed to address a possible blood transfusion reaction (increase in body temperature by 2.5 degrees). This deficient practice has the likelihood to cause harm to all patients receiving blood transfusions.
Findings include:
1. Review of Blood Transfusion record dated 4/3/14 for patient # 15 revealed the following:
a. Blood transfusion imitated at 1:30 p.m. body temperature 96.9. Post transfusion at 6:00 p.m. body temperature 99.4. No documentation found that the increase in body temperature was addressed.
b. Review of Blood and Tissue Center shipment dated 4/3/14 for patient # 15 revealed that the packed red blood cells were delivered to the facility at 08:00 a.m. The blood transfusion was not initiated until 1:30 p.m. (5.5 hours after arrival to the facility)
2. Review of policy and procedures titled Blood/Blood Components revised 7/1/12 stated:
Ideally blood is to be started within 30 minutes of receipt from blood bank. Under no circumstances is blood to be stored in refrigerator on the nursing unit. If unable to give within 30 minutes return blood to blood bank.
3. Revision of Blood and Blood Components Administration issued 6/2013 stated:
Products not started within 30 minutes of issue from transfusion services must be returned. Monitor for blood transfusion reaction signs and symptoms: Temperature elevation of 2 degrees or more Fahrenheit.
4. An interview conducted on 4/9/14 with S3 after his own review confirmed the findings above. S3 stated he was unaware that the policy stated that blood not given in 30 minutes of receipt should be returned to the blood bank.

5. An interview conducted with S9 on 4/9/14 after her own review confirmed the above findings. When asked where was blood stored once received from the blood bank S9 stated it remains in the shipping box for up to 24 hours. S9 could not produce documentation that a unit of blood could remain in the shipping box for up to 24 hours and be safely administered to a patient. S9 could not show evidence that when blood arrived to the unit or remained in the shipping box for hours that the temperature of the blood was maintained.

1. Based on record review and interviews, the facility failed to ensure that a current diet manual was approved by the medical staff and available to all staff.

Findings included:

Record review on 04/09/14 of available diet manuals revealed a written diet manual published by Becky Dorner & Associates in 2006 and an on-line publication entitled Nutrition Care Manual published by the Academy of Nutrition and Dietetics.

Interview on 04/08/14 at 11:30 AM with the facility Director of Food Services revealed that he was not aware of the written or on-line diet manuals.

Interview on 04/09/14 at 1:25 PM with the facility Dietitian revealed that she primarily utilized the on-line manual as a patient resource. She stated the on-line manual is not user friendly and therefore would be difficult for all staff to utilize. She stated that is why she had the written diet manual as a resource for staff.

She stated that she did not believe the written and/ior on-line diet manuals had been approved by the medical staff. She stated that prior to January 2014, the facility dietary services had been a contract service. She indicated she had asked the Chief Executive Officer (CEO) but had not received a verification of the diet manuals being approved.

Record review on 04/09/14 of Policy and Procedure for Food and Nutrition Services, signed by the Dietitian, Chief Nursing Officer, Chief Executive Officer, and the Medical Director on 01/20/14 did not contain information on available diet manuals.

1. Based on a tour of the facility kitchen, interviews, and record reviews, the facility failed to ensure the kitchen was clean and safely maintained.

Findings included:

A. A tour of the facility kitchen on 04/08/14 from 11:00 AM to 11:30 AM revealed the following:

1. Facility kitchen staff were observed preparing food next to uncovered trash cans with trash in the cans.

2. The handwashing sink was dirty..

3. The tray holder used deliver food to the patient rooms was dirty.

4. A build-up of dust and dirt was observed behind the stove in the kitchen.

5. Lint was observed hanging from the light fixtures in the kitchen.

6. The food steamer was not in working order.

7. The refrigerator and walkin freezer doors were dirty.

8. The refrigerator and walk-in freezer had a tag for the March 2014 and the last date temperatures were taken was 03/29/14.

9. White bins of bread crumbs, flour, and rice were observed without being dated.

10. An unlabeled frozen drink with a straw was observed in the walk-in freezer.

11. Food supplies including diet drinks, water bottles, oil, tea, and mayonnaise jars were observed on the kitchen floor.

12. Empty boxes and crates were on the kitchen floor.

B. Interview on 04/08/14 at 11:30 AM with the Director of Food Services confirmed the above listed findings. He stated the food was on the floor because the food order had arrived last night and the kitchen staff hadn't put the food supplies up at this point in time. He stated the frozen drink in the walk-in freezer belonged to a patient. He confirmed it was not labeled. He confirmed he did not have a written cleaning schedule for the kitchen staff to follow. He stated he had recently revised the Food and Nutrition Policies and Procedures.

C. Record review of the Food and Nutrition Policies and Procedures, approved on 01/20/14 by the Dietitian, the Chief Nursing Officer, the Chief Executive Officer, and the Medical Director revealed but was not limited to the following:

1. All empty boxes, crates and other packaging are disposed of immediately to alleviate potential harboring places for vermin.

2. An adequate storage room must be provided to allow all food containers to be stored off the floor (6 inches or above) on clean shelves, racks, dollies or other clean surfaces, and in such a manner as to be protected from splash and other contamination.

3. The temperature of all cool storage facilities should be checked and logged on the appropriate form at least every 24 hours with deviations from the norm reported and action recommended or taken recorded.