HospitalInspections.org

Based on record review and interview, the hospital failed to meet the requirements for the Condition of Participation of Governing Body as evidenced by failing to have a governing body which is effective in carrying out its responsibilities for the conduct of the hospital. This is evidenced by:

1) The Governing Body failed to ensure all physicians and nurse practitioners providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by failure of the hospital to credential and grant appropriate privileges for 1(S4NP) of 2 (S4NP, S7NP) total nurse practitioners managing the hospital's inpatients' care for 7 (#1,#2,#3,#4, #8, #9, #10) of 10 patients reviewed who were medically managed by S4NP. (See findings in A-0045).

2) The Governing Body failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine ( radiology) services, was credentialed and privileged, in accordance with Medical Staff By-Laws for 5 (S5Rad, S6Rad, S15Rad, S16Rad, and S20Rad) of 5 radiologists who signed imaging interpretations reviewed on 5 (#2, #3, #4, #14, #25) of 5 (#2, #3, #4, #14, #25) medical records reviewed with radiology reports from a total patient sample of 30 records. (See findings in A-0052).

3) The Governing Body failed to ensure the institution had an overall institutional plan that included a projection of capital expenditures for at least a 3 year period. This deficient practice was evidenced by the hospital's failure to provide the requested documentation of an overall institutional plan that included a projection of capital expenditures for at least a 3 year period. (See findings in A-0073).

4) The Governing Body failed to ensure all services furnished in the hospital, including contracted services, were performed in a safe and effective manner. This deficient practice was evidenced by failing to ensure all services, including contracted services, were included in the quality assurance and performance improvement (QAPI) program. (See findings in A-0083).

5) The Governing Body failed to ensure a list of all contracted services, including the scope and nature of the services provided, was maintained. (See findings in A-0085).

6) The Governing Body failed to ensure there were written policies in place for appraisal of persons experiencing a medical emergency that included initial treatment and referral, when appropriate, due to emergency services not being part of the services provided by the hospital. (See findings in A-0093).

Based on record reviews and interview, the hospital failed to meet the requirement of the Condition of Participation for the QAPI program as evidenced by:
1) Failure of the hospital to identify the following survey identified deficient practices as problems/areas in need of improvement to be addressed through the QAPI program:
a) failure to identify glucose quality controls were not being performed daily leading to patients being administered insulin coverage based on capillary blood glucose reading that may have been inaccurate;
b) failure to identify patients were being admitted by nursing staff without obtaining orders from a physician or a LIP credentialed and privileged to admit patients to the hospital;
c) failure to identify skin/wound assessments were not being accurately performed, wounds were not being reassessed for worsening, and wound specialist consults were not being ordered;
d) failure to identify medications were not being administered as ordered resulting in failure to accurately capture medication errors; and
e) failure to identify all physicians and LIPs, including radiologists providing teleradiology services, were not credentialed and privileged to provide those services at the hospital. ( See Findings at tag A-0283); and

2) Failure of the hospital to ensure the QAPI program analyzed adverse events that could impact patient safety as evidenced by failure of the hospital to analyze the cause of a grease fire in the kitchen and the cause of failure of the suppression system to be activated. (See Findings at tag A-0286);

Based on observation, record review and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) failure of the RN to ensure wounds were accurately assessed on admit, reassessed to evaluate for worsening or improvement, and/or failure to obtain wound consults for 3 (#3, #4, #5) of 3 sampled patients reviewed for wounds from a total patient sample of 30 (See findings in tag A-0395);

2) failure of the RN to ensure daily quality control testing was performed on individual capillary blood glucose meters placing patients at risk for receiving insulin coverage based on results that could possibly be inaccurate for 2 (#2, #3) current Diabetic inpatients and all future Diabetic patients receiving insulin coverage based on capillary blood glucose results obtained via glucose meter (See findings in tag A-0395); and

3) failure of the RN to obtain patient admission orders from a licensed independent practitioner who was credentialed and privileged at the hospital for 4 (#3,#4,#5,#8) of 9 ( #1-#9) sampled patients reviewed for the admission process from a total patient sample of 30 (See findings in tag A-0395).

Findings:

1) Failure of the RN to ensure wounds were accurately assessed on admit, reassessed to evaluate for worsening or improvement, and/or failure to obtain wound consults.


An Immediate Jeopardy situation was identified on 3/19/19 at 4:53 p.m. and reported to S1Adm and S2DON. The Immediate Jeopardy situation was a result of the hospital failing to ensure wounds were accurately assessed, failure to document wound reassessments to evaluate for worsening or improvement, and/or failure to obtain wound consults (with wound specialists for assessment and wound debridement) for 3 (#3, #4, #5) of 5 patients admitted with wounds.

On 3/20/19 at 3:45 p.m. S1Adm presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1.Wound care policies and procedures were prepared for education in-service along with an education acknowledgement form. A wound care policy education manual was created and placed at the nurses' station for reference.

2.Immediate in-servicing was initiated with nursing personnel- RNs, LPNs, and CNAs on 3/19/19. In-service is ongoing until all nursing personnel are educated. The in-service education included: review of policy for admission skin assessments of patients with wounds are assessed by the RN; assessments include a thorough assessment to include photos, measurements, description and indication of a treatment plan as well as communication of findings via documentation in record and directly to physician and/or wound medicine team. A Braden Skin Risk score will be completed by the admitting RN, weekly assessments of the wounds with photos, measurements, description, updates to treatment plan as needed, and communication with the physician and/or wound medicine team.

3.Frequency of monitoring: Continuous and ongoing monitoring by the direct care staff - daily for 30 days to evaluate improvement, then weekly for continued compliance. Monthly summary to QA/PI and quarterly reporting.

Review of documentation presented revealed staff present when the IJ was called and staff who had worked the night shift of 3/19/19 and the day shift of 3/20/19 had been educated on the hospital's skin assessment policies and procedures referenced above.

In an interview on 03/20/19 at 4:00 p.m., S2DON indicated she had not performed the skin audit/wound assessment for Patient #4 as of the time of this interview.

The IJ remained in place on 3/20/19 due to the hospital's failure to complete body audits (requested on 3/19/19 when the IJ was declared) on all 5 current inpatients, not just on the patients with previously identified wounds, in order to ensure there were no wounds on Patient #1 and Patient #2 that may have been missed.

Documentation of wound assessments and complete body audits of all 5 current inpatients was presented upon survey team entry on 3/21/19 by S1Adm. The body audits and wound assessments were reviewed by the survey team. The assessments included intact skin assessments on Patient #1 and Patient #2. Further review revealed wound pictures and detailed wound descriptions were documented on Patients #3, #4, and #5.

On 3/21/19 at 11:45 a.m. documentation of staff education regarding wound care was presented by S1Adm to the survey team. The information was reviewed and staff education was verified.

On 03/21/19 at 12:30 p.m. an interview was conducted with S10RN and she verbalized she had received in-service/education regarding wound care and documentation.


The Immediate Jeopardy was lifted on 3/21/19 at 1:25 p.m. However, there was not enough evidence to determine sustainability of compliance with the Condition of Participation for Nursing Services for the Condition to be cleared. Noncompliance remains at the Condition Level.



2) Failure of the RN to ensure daily quality control testing was performed on individual capillary blood glucose meters.


An Immediate Jeopardy situation was identified on 3/19/19 at 4:53 p.m. and reported to S1Adm and S2DON. The Immediate Jeopardy situation was a result of the hospital failing to ensure daily quality control testing was performed on individual capillary blood glucose meters placing patients at risk who were receiving insulin coverage based on results that could possibly be inaccurate for 2 (#2, #3) of 2 current Diabetic inpatients and all future diabetic patients receiving .

On 3/20/19 at 3:45 p.m. S1Adm presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1.The policy for "Glucose Monitoring Quality Control" was revised to reflect current glucometer devices in use with procedures for conducting quality control testing and policy for daily testing requirements.

2.Proper control testing solution devices in use, secured from pharmacy immediately.

3.New Quality Control log for blood glucose testing developed.

4.Immediate in-servicing was initiated with nursing personnel - RNs, LPNs, and CNAs on 3/19/19. In-service is ongoing until all nursing personnel are educated. The in-service education included review of policy for control testing of glucose monitoring devices, requirements for testing daily on the night shift, reporting of low solution supply or unavailability, and use of the quality control log.

5.Verbal approval of the new polices and procedures for glucose meter quality control testing from Governing Board President.

6.Frequency of monitoring: Continuous and ongoing monitoring by the direct care staff- daily check for compliance with testing log per device, use and availability of solution for 90 days to evaluate improvement, then weekly and monthly checks thereafter for continued compliance. Monthly summary to QA/PI and quarterly reporting.

Review of the provided staff education documentation, presented to the survey team by S1Adm on 3/20/19, revealed a sign in sheet with staff names indicating they had been in-serviced on the above referenced policies.

The policies referenced above were provided to the survey team, by S1Adm, on 3/20/19 and they were reviewed.

The Quality Control log for individual blood glucose meter testing was presented to the survey team by S1Adm. The log was reviewed and at the time the log was presented there had only been one quality control test performed.

The IJ remained in place on 3/20/19 due to the hospital's only having completed one quality control test.


On 3/21/19 at 11:45 a.m. documentation of staff education regarding quality control testing for individual glucose testing was presented to the survey team by S1Adm . The information was reviewed and staff education was verified.

Review of the Quality Control log for individual glucose meter testing, on 3/21/19, revealed the most recent controls were run on 03/21/19 at 1:00 a.m. (run nightly as per policy).

On 03/21/19 at 12:30 p.m. an interview was conducted with S10RN and she verbalized she had received in-service education regarding quality controls for individual blood glucose meter testing and the policies related to quality controls for blood glucose meter testing.


The Immediate Jeopardy was lifted on 3/21/19 at 1:25 p.m. However, there was not enough evidence to determine sustainability of compliance with the Condition of Participation for Nursing Services for the Condition to be cleared. Noncompliance remains at the Condition Level.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to ensure patient medical records were promptly completed, readily accessible, and protected from damage or loss. This deficient practice was evidenced by failure to ensure all medical records were completed by physicians/LIPs within 30 days after discharge as evidenced by S3MedDir having 9 medical records that were over 30 days delinquent and 3 medical records that were over 60 days delinquent; failure to ensure patient medical records were easily retrieved and readily accessible as evidenced by having no access to patient records from 11/1/17 - 9/21/18; and failure to ensure all medical records were stored in secured locations and protected from damage or loss. (see findings at A-0438).

2) Failing to develop a system for coding and indexing medical records that allowed timely retrieval of medical records. (see findings at A-0440).

3) Failing to ensure all clinical records, including physician/NP progress notes and orders, were dated and timed when written or authenticated. This deficient practice was evidenced by failure to have progress notes and orders with no documented evidence of the date and/or time the note or order was written or authenticated for 6 (#1, #3, #4, #5, #8, #9) of 9 (#1- #9) patient records reviewed for dating, timing, and authentication of entries from a sample of 30 patients. (see findings at A-0450).

4) Failing to ensure all records contained a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by failure of the physician to time and date his authentication on the H&P to be able to determine that the H&P was completed and in the medical record within 24 hours of admission for 5 (#2, #3, #8, #9, #10) of 10 (#1 - #10) patient records reviewed for H&Ps from a sample of 30 patients. (see findings at A-0458).

5) Failing to ensure medical records included a properly executed informed consent for admission and treatment, authorization to release information and assignment of insurance benefits. This deficient practice was evidenced by informed consents for admission and treatment, authorization to release information and assignment of insurance benefits were not completed for 8 (#12, #13, #14, #15, #16, #17, #18, #29) of 8 discharged patients reviewed for properly executed informed consents. (see findings at A-0466).

Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Food and Dietetic Services. This deficient practice is evidenced by:
Failure of the hospital to ensure individual patient nutritional needs were met in accordance with recognized dietary practices due to failure to have a system in place to provide meals for 2 (#2, #3) current inpatients on special diets, 2 (#1, # 5) current inpatients on regular diets, and all future patients admitted while the kitchen was closed due to issuance of a cease and desist for use of all current cooking equipment by the State Fire Marshall on 3/19/19 at 3:27 p.m. The cease and desist left the hospital with no means for provision of meal service for the dinner service on 3/19/19 and future meal services for the duration of the cease and desist. (See findings under tag A-0629).


An Immediate Jeopardy situation was identified on 3/19/19 at 4:53 p.m. and reported to S1Adm and S2DON. The Immediate Jeopardy situation was a result of the hospital failing to have a system in place to provide meals for inpatients on special diets (Patient # 2 - diabetic diet and Patient #3 - cardiac, low fat, low sodium, and low cholesterol diet) and on regular diets (Patient #1 and Patient #5) when the hospital's kitchen was closed on 3/19/19 at 3:27 p.m. by the State Fire Marshall due to issuance of a cease and desist for use of all current cooking equipment. The cease and desist for all cooking equipment left the hospital with no means for provision of meal service for the dinner service on 3/19/19 and future meal services for the current inpatients for the duration of the cease and desist.

On 3/20/19 at 3:45 p.m. S1Adm presented the 1st plan for lifting the immediacy of the IJ situation and the plan included the following:

1. The next meal service (5:45 p.m.) on 3/19/19 was provided by securing special diet food trays/meals from an area acute care hospital's food service provider Company B.

2. Arrangements were made on 3/19/19 with Hospital A whose food service is through Company B to secure 3 meals for the patient census on 3/20/19 and will continue for a temporary period (through 3/24/19), pending the hospital securing a food/meal vendor agreement with " most likely Company B". The hospital was awaiting a temporary agreement with Hospital A. The next scheduled meal service was for 3/21/19. Kitchen/Dietary personnel will be responsible for securing the food trays from Hospital A, serving the patient trays, return of dishes, thermal containers to Hospital A.
3. Administrator met with the new building owner to discuss the repairs/maintenance required for the stove hood and extinguishers to correct deficiency shortly. Once repaired, notification to the State Fire Marshall will take place for their reassessment and reinstatement of use of use of the kitchen to prepare meals.
4. Frequency of monitoring: Daily monitoring by S1Adm to ensure compliance with daily meal adequacy until reinstatement of onsite meal preparation by Dietary personnel. Then routine monthly QI monitoring by dietary personnel will resume. Monthly summary to QA/PI and quarterly reporting.
5. Verbal approval of administrative actions obtained from the Governing Board President.
In an interview on 3/20/19 at 4:15 p.m. with S1Adm, she confirmed the meals to be provided through 3/24/19 by Hospital A were for special diets only and no arrangements had been included for providing regular patient meals. S1Adm indicated regular meals had been obtained from area fast food restaurants that served sandwiches and fried chicken. She also confirmed no agreement had been obtained for provision of patient meals after 3/24/19.
The IJ remained in place due to failure of the hospital to secure provision of regular meals from an accepted vendor and failure to secure a contract to cover future meal services (after 3/24/19).

In an interview on 3/21/19 at 12:07 p.m., S1Adm indicated the hospital currently had 5 patients and the meals on 3/20/19 (dinner) and today for all current inpatients were provided by Hospital A. She further stated as of now it is her understanding the owners of the building they currently reside would probably turn off the gas to the kitchen to remodel that area resulting in the hospital being unable to use the kitchen in the future.

In an interview on 3/21/19 at 12:40 p.m., S1Adm reported she had spoken to the Administrator of Company B and they agreed to provide their meals. S1Adm indicated she was awaiting a preliminary agreement/contract for their meal service.

In an interview on 03/21/19 at 1:33 p.m. with the Administrator of Company B, he verified there was a verbal contract to provide all inpatient meals. He confirmed the attorneys were typing up the contract regarding Company B providing meals for all the patients at this hospital beginning on March 25, 2019. The contract was to be emailed by the close of business on 3/21/19.

The Immediate Jeopardy was lifted on 3/21/19 at 1:35 p.m. However, there was not enough evidence to determine sustainability of Compliance with the Participation for Food and Dietetic Services for the Condition to be cleared. Noncompliance remains at the Condition Level.

Based on record review and interview, the hospital failed to meet the Condition of Participation for Utilization Review as evidenced by:
1) Failing ensure a UR committee, including two physician members, who were doctors of medicine or osteopathy, was established. (See findings in tag A-0654).

Based on observations, review of hospital documentation, and interviews , the hospital failed to meet the Condition of Participation relative to the physical environment as evidenced by failing to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients, staff, and visitors and resulted in the State Fire Marshal placing the hospital on a Fire Watch to remain in effect until the Office of the State Fire Marshal has conducted an inspection rescinding the Fire Watch. This was evidenced by:

1. Failure to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors as evidenced by failure to maintain a clean and safe environment as evidenced by multiple breaches in the quality and safety in the environment of care. (See findings in tag A-0724).

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control as evidenced by:

1) Failing to ensure a person or persons was designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases as evidenced by failure to have documented evidence of experience and training in current infection control practice for 2 (S1Adm, S2DON) employees designated as infection control officers (see findings in tag A0748).

2) Failing to ensure the infection control officer developed and implemented a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:
a) Failing to implement HAI risk mitigation measures as evidenced by observation of breaches in hand hygiene on 03/19/19;
b) Failing to maintain a sanitary physical environment as evidenced by improper techniques for food sanitation, breaches in techniques for cleaning and disinfecting environmental surfaces, unsuccessful techniques for pest control, having stained and missing ceiling tiles and stained toilets in patient bathrooms as observed during an environmental tour conducted on 03/18/19 at 8:50 a.m. and 10:50 a.m.
c) Failing to track, measure, analyze, and trend infections as evidenced by having the tracking report and log void of documentation;
d) Failing to implement hospital staff-related measures as evidenced by (i) failure to have current TB test results in accordance with the OPH guidelines for 3 (S2DON, S10RN, S18RT) of 6 (S1Adm, S2DON, S10RN, S11RN, S12HK, S18RT) employee/contract staff and 2 (S3MedDir, S7NP) of 2 physician/nurse practitioner personnel/credentialing files reviewed for TB test results and (ii) failure to have documented evidence of new employee and regular update training in preventing and controlling HAI and methods to prevent exposure to and transmission of infections and communicable diseases for 9 (S1Adm, S2DON, S9RN, S10RN, S11RN, S12HK, S13DM, S17Diet, S18RT) of 9 employee/contract staff personnel files reviewed for infection control training (see findings in tag A0749).

3) Failing to ensure the administrator, medical staff, and DON ensured the hospital-wide QAPI program addressed problems identified by the infection control officer(s) and was responsible for the implementation of successful corrective action plans in the affected problem areas as evidenced by failure to have infection control data collected, measured, analyzed, and trended with results addressed in the QAPI program and corrective action developed to address problem areas (see findings in tag A0756).

Based on record review of the contracts, hospital policy and procedures, and interview with the Administrator, the hospital failed to meet the requirements of the Condition of Participation for Organ, Tissue, and Eye Procurement as evidenced by:

1. Failing to have written policies and procedures in place to address the hospital's organ, tissue, and eye procurement responsibilities. (see findings at A-0885).

2. Failing to ensure written protocols were established for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital. This deficient practice was evidenced by failure of the hospital to establish written protocols for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital. (see findings at A-0886).

3. Failing to have an agreement with at least one eye bank and tissue bank to cooperate in the retrieval, processing, preserving, storage and distribution of eyes of potential donors. (see findings at A-0887).

Based on record reviews and interview, the hospital failed to meet the requirement of the Condition of Participation for the Establishment of the Emergency program as evidenced by:

1) Failing to ensure its EP plan was reviewed and updated at least annually as evidenced by not having the plan reviewed and updated since 06/11/13 (see findings in tag E0004).

2) Failing to ensure its EP plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach as evidenced by failure to have a documented assessment for review (see findings in tag E0006).

3) Failing to ensure its EP plan included policies and procedures for safe evacuation from the hospital that included consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation locations, and primary and alternate means of communication with external sources of assistance as evidenced by failure to have an updated EP that included these requirements (see foindings in tag E0020).

4) Failing to ensure its EP plan included policies and procedures for a means to shelter in place for patients, staff, and volunteers who remain in the hospital as evidenced by the EP not including sheltering in place procedures (see findings in tag E0022).

5) Failing to ensure its EP plan included policies and procedures related to a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records as evidenced by failure of the EP to address the specific procedures for medical documentation to assure preservation of information, confidentiality of patient information, and the availability of records (see findings in tag E0023).

6) Failing to ensure its EP plan included a method for sharing information and medical documentation for patients under its care with other health providers to maintain the continuity of care, the means, in the event of an evacuation, to release patient information, and the means of providing information about the general condition and location of patients under the hospital's care as evidenced by failure to have policies and procedures developed that address these topics (see findings in tag E0033).

7) Failing to ensure its EP training program included training in EP policies and procedures to all new and existing staff and individuals providing services under arrangement upon hire and at least annually, maintained documentation of the training, and included demonstration of staff knowledge of emergency procedures. This deficient practice was evidenced by failure to have documented evidence that EP training had been conducted upon hire and at least annually with documentation of the demonstration of staff knowledge of emergency procedures for 12 (S1Adm, S2DON, S3MedDir, S4NP, S7NP, S9RN, S10RN, S11RN, S12HK, S13DM, S17Diet, S18RT) of 12 personnel/credentialing files reviewed for EP training (see findings in tag E0037).

Based on record review and interview, the governing body failed to ensure all physicians and nurse practitioners providing services in the hospital were credentialed and granted appropriate privileges. This deficient practice was evidenced by failure of the hospital to credential and grant appropriate privileges for 1(S4NP) of 2 (S4NP, S7NP) total nurse practitioners managing the hospital's inpatients' care for 7 (#1,#2,#3,#4, #8, #9, #10) of 10 patients reviewed who were medically managed by S4NP.

Findings:


A list of credentialed physicians and LIPs, with specialty, was requested from S2DON on survey team entry on 3/18/19. The list was also requested on 3/19/19 and 3/20/19. No list was provided prior to survey team exit on 3/21/19.

Patient #1
Review of Patient #1's medical record revealed S4NP had written progress notes dated 2/21/19, 2/22/19, 2/28/19, 3/1/19, and 3/2/19 documenting assessments of the patient's progress and plans for continued care.

Patient #2
Review of Patient #2's medical record revealed history and physical dated 02/28/19 was signed by S4NP. Further review revealed S4NP had written orders on 03/01/19 and 03/06/19.

Patient #3
Review of Patient #3's medical record revealed orders were written or verbally given by S4NP on 02/14/19, 02/19/19, 02/21/19, 02/23/19, 02/24/19, and 03/05/19. Further review revealed progress notes were documented by S4NP on 02/16/19, 02/17/19, 02/19/19, 02/20/19, 02/21/19, 02/24/19, and 02/25/19.

Patient #4
Review of Patient #4's medical record revealed orders were written by S4NP on 03/05/19 and 03/06/19. Further review revealed a progress note was documented by S4NP on 02/14/19.

Patient #8
Review of Patient #8's medical record revealed history and physical dated 11/19/18 was signed by S4NP. Further review revealed progress notes were signed by S4NP on 11/22/18 and 11/26/18. Further review revealed discharge summary dated 11/27/18 was signed by S4NP.

Patient #9
Review of Patient #9's medical record revealed a progress note was documented by S4NP on 11/22/18. Further review revealed orders were written by or received verbally from S4NP on 11/21/18 and 11/22/18.

Patient #10
Review of Patient #10's medical record revealed history and physical dated 11/29/18 was signed by S4NP.

In an interview on 3/20/19 at 4:00 p.m. with S1Adm, she confirmed the only credentialing files she had were for S3MedDir and S7NP. She verified S4NP was managing inpatients and verified there was no credentialing file for S4NP.





25065




39791

Based on record review and interview, the hospital failed to ensure each physician/practitioner providing services in the hospital, including radiologists performing telemedicine ( radiology) services, was credentialed and privileged, in accordance with Medical Staff ByLaws for 5 (S5Rad, S6Rad, S15Rad, S16Rad, and S20Rad) of 5 radiologists who signed imaging interpretations reviewed on 5 (#2, #3, #4, #14, #25) of 5 (#2, #3, #4, #14, #25) medical records reviewed with radiology reports from a total patient sample of 30 records.


Findings:

Review of the hospital's Medical Staff By-Laws revealed the following, in part: 2.D. Telemedicine: All individuals applying for medical staff membership, who are responsible for patient care, treatment, or service via a telemedicine link shall apply for medical staff membership and clinical privileges through one of the following mechanisms: (c) The hospital uses credentialing and privileging from the distant site where the individual provides telemedicine services to make a final decision on the individual's application and clinical privileges if the following requirements are met: (2): The individual is privileged at the distal site for those services provided at the hospital.

Patient #2
Review of Patient #2's medical record revealed a radiology report of one view of chest dated 03/04/19 was documented by S6Rad, and a radiology report of one view of chest dated 03/11/19 was documented by S5Rad.

Patient #3
Review of Patient #3's medical record revealed a radiology report of one view of the chest dated 02/22/19 was documented by S16Rad, and a radiology report of one view of the abdomen dated 02/20/19 was documented by S5Rad. Further review revealed a radiology report of 3 views of the left knee and 3 views of the right knee were documented by S20Rad.

Patient #4
Review of Patient #4's medical record revealed a radiology report of one view of the chest dated 02/20/19 was documented by S5Rad, and a report of one view of the chest dated 03/04/19 was documented by S6Rad.

Patient #14
Review of Patient #14's medical record revealed S15Rad had interpreted Patient #14's chest x-ray on 11/12/18.

Patient #25
Review of Patient #25's medical record revealed S6Rad had interpreted Patient #25's chest x-ray on 2/11/19. Further review revealed S5Rad had interpreted Patient #25's chest x-rays on 1/21/19 and 1/30/19.


A list of credentialed physicians and LIPs, with specialty, was requested from S2DON on survey team entry on 3/18/19. The list was also requested on 3/19/19 and 3/20/19. No list was provided prior to survey team exit on 3/21/19.

In an interview on 3/19/19 at 11:00 a.m., S1Adm had indicated S16Rad and S20Rad were the hospital's only credentialed and privileged radiologists.

In an interview on 3/20/19 at 4:00 p.m. with S1Adm, she confirmed the only credentialing files she had were for S3MedDir and S7NP. S1Adm verified there were no credentialing files for S5Rad, S6Rad, S15Rad, S16Rad, and S20Rad.




25065




38777




39791

Based on record review and interview, the hospital failed to ensure the institution had an overall institutional plan that included a projection of capital expenditures for at least a 3 year period. This deficient practice was evidenced by the hospital's failure to provide the requested documentation of an overall institutional plan that included a projection of capital expenditures for at least a 3 year period.

Findings:

An overall institutional plan that included a projection of capital expenditures for at least a 3 year period was requested (both verbally and in writing in the survey document request list), upon survey team entry on 3/18/19 .

The requested institutional plan with capital expenditures for at least a 3 year period was not provided by S1Adm.

In an interview on 3/20/19 at 4:00 p.m. with S1Adm, she confirmed the requested documents had not been provided.


39791

Based on record review and interview, the governing body failed to ensure all services furnished in the hospital, including contracted services, were performed in a safe and effective manner. This deficient practice was evidenced by failing to ensure all services, including contracted services, were included in the quality assurance and performance improvement (QAPI) program.

Findings:

Review of the contracts provided by S1Adm revealed Radiology Services and Pharmacy Services were provided via contract. S1Adm also reported Lab Services were provided by contract as well.

In an interview on 3/20/19 at 4:00 p.m. with S1Adm, she confirmed there was no performance improvement data for Radiology, Pharmacy, and Lab Services.

Based on requested document review and interview, the hospital failed to ensure a list of all contracted services, including the scope and nature of the services provided, was maintained.

Findings:

A list of all of the hospital's contracted services that included the scope and nature of the services provided by contracted providers was requested from S2DON on survey team entry on 3/18/19.

Review of the documents provided for survey review revealed there was no list of contracted services included in the documents provided to the survey team by S1Adm.

In an interview on 3/19/19 at 10:00 a.m. with S1Adm, she confirmed she did not have a current list of contracted services.

Based on policy review and interview, the hospital's governing body failed to ensure there were written policies in place for appraisal of persons experiencing a medical emergency that included initial treatment and referral, when appropriate, due to emergency services not being part of the services provided by the hospital.

Findings:

Review of the hospital's policies revealed no written policies addressing appraisal of persons experiencing medical emergencies, initial treatment of those persons, and referral when appropriate.

In an interview on 3/20/19 at 3:50 p.m. with S1Adm, she confirmed the hospital had no written policies for appraisal of persons experiencing medical emergencies, initial treatment of those persons, and referral when appropriate.

Based on record reviews and interviews, the hospital failed to ensure each patient was presented a copy of the Patient's Bill of Rights before discharge. This deficient practice was evidenced by failure to maintain a copy of the Patient's Bill of Rights, signed by the patient /patient's family/representative, to indicate the patients had been informed of their rights prior to discharge for 4 (#12, #18, #23, #29) of 4 (#12, #18, #23, #29) discharged records reviewed for Patient's Bill of Rights from a total patient sample of 30.

Findings:

Patient #12
Review of the medical record for Patient # 12 who was admitted 11/13/18 and discharged 11/21/18 failed to reveal a signed copy of the Patient's Bill of Rights.

Patient #18
Review of the medical record for Patient #18 who was admitted 11/14/18 and discharged 11/17/18, readmitted 11/21/18 and discharged on 12/5/18 failed to reveal a signed copy of the Patient's Bill of Rights.

Patient #23
Review of the medical record for Patient #23 who was admitted 12/28/2018 and discharged 12/31/18 failed to reveal a signed copy of the Patient's Bill of Rights.

Patient #29
Review of the medical record for Patient #29 who was admitted 1/27/19 and discharged 2/13/19 failed to reveal a signed copy of the Patient's Bill of Rights.

In an interview on 3/20/19 at 1:50 p.m., with S2DON, she verified there was no documented evidence the above patients received and signed the Patient's Bill of Rights. She also confirmed the documents should have been signed by the patient or family/representative and maintained in the medical record.

Based on record review and interview, the hospital failed to ensure opportunities for improvement were identified, through the hospital wide QAPI program, that could affect health outcomes, patient safety and quality of care. This deficient practice was evidenced by failure of the hospital to identify the following survey identified deficient practices as problems to be addressed through the QAPI program:
a) failure to identify glucose quality controls were not being performed daily leading to patients being administered insulin coverage based on capillary blood glucose reading that may have been inaccurate;
b)failure to identify patients were being admitted by nursing staff without obtaining orders from a physician or a LIP credentialed and privileged to admit patients to the hospital;
c)failure to identify skin/wound assessments were not being accurately performed, wounds were not being reassessed for worsening, and wound specialist consults were not being ordered;
d)failure to identify medications were not being administered as ordered resulting in failure to accurately capture medication errors; and
e)failure to identify all physicians and LIPs, including radiologists providing teleradiology services, were not credentialed and privileged to provide those services at the hospital.

Findings:

a) Failure to identify glucose quality controls were not being performed daily leading to patients being administered insulin coverage based on capillary blood glucose reading that may have been inaccurate.

On 3/19/19 at 4:53 p.m. an immediate jeopardy was called related to failure of the hospital to perform daily glucose meter quality controls.

In an interview on 3/20/19 at 2:30 p.m. S1Adm confirmed failure to perform daily glucose meter quality controls and the potential impact that could have on patients receiving insulin coverage based on results that could possibly be inaccurate was not identified as a problems to be addressed through the hospital's QAPI program.

b) Failure to identify patients were being admitted by nursing staff without obtaining orders from a physician or a LIP credentialed and privileged to admit patients to the hospital.

Patient #3
Review of Patient #3's "Admission Orders" dated 02/11/19 at 3:30 p.m. revealed the orders were documented as "RBO Admit Orders from Hospital B" and noted by S2DON.

Patient #4
Review of Patient #4's "Admission Orders" dated 02/13/19 at 1:00 p.m. revealed documentation by the RN that "orders rewritten for S3MedDir" with no documented evidence that the orders had been obtained from and read back to S3MedDir. Further review revealed "Facility Transfer Orders" from Hospital C were included in the admit orders.

In an interview on 03/19/19 at 1:45 p.m., S2DON indicated she gets the physician orders from the orders received from the referring hospital. She indicated when she documents VRBO she's verifying the orders from the referring hospital. She further indicated she doesn't read the orders to S3MedDir unless she has a question about the order. S2DON confirmed this system is how all patient orders are done. She further indicated she isn't getting admit orders from S3MedDir, because the patient is coming with their admit orders from the transferring hospital.

Patient #5
Review of Patient #5's admission orders, dated 3/6/19 at 4:30 p.m., revealed the orders were signed by S2DON and had not been signed by a physician or a LIP as of 3/19/19 (date of record review). The orders had not been documented as verbal orders.

In an interview on 3/19/19 at 2:30 p.m. with S2DON, she indicated she had written the admission orders based on the information provided by the referring NP who had been treating Patient #5 in the home. S2DON confirmed the NP had not been employed by the hospital and was not credentialed and privileged to admit patients. S2DON indicated she filled out the admission orders based on the expectations of the hospital's medical staff and not based on formal, approved standing orders.

Patient #8
Review of Patient #8's medical record revealed the patient was admitted on 11/18/18 and discharged on 11/27/18.

On 03/19/19 at 1:50 p.m. in an interview with S2DON, she verified Patient #8's admission orders were based on the Pre-Admission history and assessment by S21LPN dated 11/08/18.

c)Failure to identify skin/wound assessments were not being accurately performed, wounds were not being reassessed for worsening, and wound specialist consults were not being ordered.

On 3/19/19 at 4:53 p.m. an Immediate Jeopardy was called related to failure of the RN to accurately assess wounds, failure to implement wound care, failure to order consults for wound care specialists to evaluate and debride wounds, and failure to document reassessments to evaluate for improvement or worsening of wounds for 3 ( #3, #4, and #5) patients reviewed for wounds.

d)Failure to identify medications were not being administered as ordered resulting in failure to accurately capture medication errors.

Patient #3
Review of Patient #3's physician orders revealed an order on 02/19/19 at 2:57 p.m. for Lasix 40 mg IV daily for 3 days, 1st dose now.

Review of Patient #3's MARs and nursing notes revealed Lasix 40 mg IV, ordered to be given now on 02/19/19 at 2:57 p.m., was not administered until 8:36 p.m. (5 hours 39 minutes after it was ordered). There was no documented evidence the physician was notified of the delay of administering Lasix on 02/19/19.

Patient #9
Review of Patient #9's medical record revealed an order on 11/22/18 at 10:21 a.m. to give Singulair 10 mg by mouth every HS, give the first dose now, and Mucinex 600 mg one by mouth BID.

Review of Patient #9's MAR and nursing notes revealed Singulair and Mucinex was not administered on 11/22/18 as ordered due to it not being available. Both medications were not administered until 11/23/18.

In an interview on 03/20/19 at 8:30 a.m., S2DON, she confirmed Singulair and Mucinex was not administered as ordered for Patient #9.

Patient #11
Review of Patient #11's physician's orders revealed an admission order for Cosopt eye drops (used for treatment of glaucoma) - 1 drop twice daily in both eyes.

Review of Patient #11's MAR revealed Cosopt eye drops were to be administered at 10:00 a.m. and 10:00 p.m. Further review revealed no documented evidence that the eye drops had been administered and no documented reason for not administering the eye drops as ordered for the 10:00 p.m. dose on the following dates: 11/15/18, 11/16/18 and 11/22/18.

Review of the information referenced above for Patients #3, #9, and #11 revealed 9 medication errors related to failure to administer medications at the right time and missed doses of ordered medications.

In an interview on 3/20/19 at 1:40 p.m. with S1Adm she reported the facility had not had any medication variances.

Interview 3/20/19 at 8:46 a.m. with S14Pharm, he reported he was not aware of any medication variances. He indicated he had been Pharmacy Director since the last quarter of last year and had not had a P & T committee meeting as of yet.

e)Failure to identify all physicians and LIPs, including radiologists providing teleradiology services, were not credentialed and privileged to provide those services at the hospital.

Review of inpatient medical records for Patients #1,#2,#3,#4, #8, #9, #10 revealed the patients were medically managed by S4NP.

Review of the credentialing files provided by S1Adm revealed there was no credentialing file for S4NP and no credentialing and privileging information could be provided by S1Adm for S4NP.

Review of signed imaging interpretations via teleradiology revealed the following:
Patient #2 had 2 images interpreted by S5Rad and S6Rad,
Patient #3 had 3 images interpreted by S5Rad, S16Rad and S20Rad,
Patient #4 had 2 images interpreted by S5Rad and S6Rad,
Patient #14 had 1 image interpreted by S15Rad, and
Patient #25 had 3 images interpreted by S5Rad and S6Rad.

Review of the credentialing files provided by S1Adm revealed there were no credentialing files for S5Rad, S6Rad, S15Rad, S16Rad, and S20Rad and no credentialing and privileging information could be provided by S1Adm for S5Rad, S6Rad, S15Rad, S16Rad, and S20Rad.
.
In an interview on 3/20/19 at 2:30 p.m. S1Adm confirmed the above referenced survey identified deficient practices had not been identified as problems/areas in need of improvement to be addressed through the hospital's QAPI program.

Based on record review and interview, the hospital failed to ensure the QAPI program analyzed adverse events that could impact patient safety. This deficient practice was evidenced by failure of the hospital to analyze the cause of a grease fire in the kitchen and the cause of failure of the suppression system to be activated.

Findings:

Review of State Fire Marshall report documentation, completed during an onsite inspection on 3/19/19, revealed a grease fire had occurred in the kitchen, on the front left burner of the range a few weeks prior to the inspection. The suppression system had not activated and was not manually activated. Further review revealed the staff had responded with the wrong type of fire extinguisher for a grease fire.

On 3/19/19 at 3:27 p.m. a cease and desist for use of all current cooking equipment was issued by the State Fire Marshall.

In an interview on 3/20/19 at 10:30 a.m. with S1Adm, she confirmed a grease fire had occurred in the hospital's kitchen on 2/9/19. She reported the fire department had been called at the time of the fire. She confirmed she had not performed a root cause analysis to investigate the cause of the fire and to identify opportunities for prevention of future occurrances. S1Adm also indicated she had failed to complete an incident report related to the kitchen fire.

Based on record review and interview, the hospital failed to ensure the medical staff enforced the Medical Staff-by Laws. This deficient practice is evidenced by failing to ensure a physician (S3MedDir) with 12 delinquent medical records ( 9 records greater than 30 days delinquent and 3 records greater than 60 days delinquent) was sent a notification letter, by the CEO, informing the physician that he had 7 days to complete the medical records or his admitting privileges would be suspended and failure to suspend the physician's admitting privileges when the records were not brought into compliance.

Findings:

Review of the Medical Staff By-laws revealed the following, in part: If the medical record is incomplete 30 days after discharge, a written notice shall be sent to the physician by the CEO notifying him that he has 7 days to complete the medical records or his admitting privileges will be suspended ...Failure to complete the medical records that caused the relinquishment of clinical privileges within 30 days from the relinquishment of such privileges shall constitute a voluntary resignation from the Medical Staff.

On 03/19/19 at 10:10 a.m., S1Adm was unable to provide a list with deficient medical records when asked for a deficient medical records list. S1Adm manually counted the medical records flagged as deficient for S3MedDir. S1Adm confirmed no letter had been sent to S3MedDir and confirmed S3MedDir's privileges had not been suspended as a result of the delinquent medical records.

Based on record reviews and interviews, the hospital failed to ensure the medical staff conducted H&P examinations in accordance with the Medical Staff By-laws as evidenced by failure of the physician/LIP to time and date his/her authentication on the H&P to be able to determine that the H&P was completed and in the medical record within 24 hours of admission for 7 (#1, #2, #3, #5, #8, #9, #10) of 10 patient records reviewed for H&Ps from a sample of 30 patients.

Findings:

Review of the "Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital", presented as the current rules and regulations by S1Adm, revealed each patient shall receive a H&P examination completed no more than 24 hours after admission, and documentation must be placed in the patient's medical record within 24 hours of admission.

Review of the policy titled "Documentation Standards", presented as a current policy by S1Adm, revealed continental (military) time must be used in all entries. Each separate entry must have a corresponding time of occurrence in the time column.

Patient #1
Review of Patient #1's medical record revealed she was admitted on 02/20/19. Further review revealed a H&P examination was documented on 02/21/19 and signed by S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 02/27/19. Further review revealed a H&P examination was documented on 02/28/19and signed by S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 02/12/19. Further review revealed a H&P examination was documented on 02/12/19 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #5
Review of Patient #5's medical record revealed the patient was admitted on 03/06/19. Further review revealed a H&P examination was documented on 03/06/19 and signed by S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/18/19. Further review revealed a H&P examination was documented on 11/19/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 11/21/18. Review of her H&P revealed it was performed on 11/22/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #10
Review of Patient #10's medical record revealed she was admitted on 11/28/19. Further review revealed a H&P examination was documented on 11/29/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

A telephone call was attempted to reach S3MedDir on 03/20/19 at 12:45 p.m. When no answer was received, a message was left on his cell phone and office phone requesting that he contact the surveyors at the hospital. No return call was received from S3MedDir as of the end of the day on 03/20/19.

In an interview on 03/20/19 at 8:30 a.m., S2DON indicated without a time documented on the H&P, she couldn't say whether the H&P was conducted within 24 hours of admission for Patients #3 and #9.




30984




39791

Based on record reviews and interview, the hospital failed to ensure each nurse providing nursing services was currently licensed to practice as evidenced by failure to have documented evidence of current licensure for 2 (S9RN, S10RN) of 4 (S2DON, S9RN, S10RN, S11RN) RN personnel files reviewed for current nursing licensure.

Findings:

Review of the personnel files of S9RN and S10RN revealed no documented evidence that each RN was currently licensed to practice nursing.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the personnel files of S9RN and S10RN did not have verification of a current nursing license.

Based on record review, observation, and interview, the hospital failed to ensure the RN supervised the care of each patient as evidenced by:

1) failure of the RN to ensure wounds/skin assessments were accurately assessed on admit and ongoing, to ensure wounds were reassessed to evaluate for worsening or improvement, and/or failure to ensure wound consults were obtained for 4 ( #1, #3, #4, #5) of 4 current sampled patients reviewed for skin assessments/wounds from a total patient sample of 30;

2) failure of the RN to ensure daily quality control testing was performed on individual capillary blood glucose meters placing patients at risk who were receiving insulin coverage based on results that could possibly be inaccurate for 2 (#2, #3) of 2 current Diabetic inpatients and all future Diabetic patients receiving insulin coverage based on capillary blood glucose results obtained via glucose meter from a total patient sample of 30;

3) failure of the RN to obtain patient admission orders from a licensed independent practitioner who was credentialed and privileged at the hospital for 4 (#3, #4 , #5, #8) of 9 (#1 - #9) patients sampled for the admission process from a total patient sample of 30; and

4) failure of the RN to implement physician orders for Accuchecks, weight, and labs and failure to ensure physician orders were obtained for all labs performed for 3 (#2, #3, #6) of 9 (#1 - #9) records reviewed for implementation of physician orders from a sample of 30 patients.


Findings:


1) Failure of the RN to ensure wounds were accurately assessed on admit and ongoing, reassessed to evaluate for worsening or improvement, and/or failure to obtain wound consults.

Review of the policy titled "Nursing Admission Process", presented as a current policy by S1Adm, revealed a wound care assessment was to be conducted by the wound care nurse within 24 hours of admission.

Review of the policy titled "Skin Care, Assessment And Maintenance Of", presented as a current policy by S1Adm, revealed all patients with potential risk for skin breakdown are screened using the Braden Risk Assessment Scale. Skin assessment shall be performed at least every 12 hours. The effectiveness of wound care treatment will be reassessed on a weekly basis and performed by a designated nurse. Rounds will be made on all patients and will include measurement and photographic documentation every week of all wounds. If the wound does not show improvement in a timely manner, the physician will be contacted to discuss a change in the treatment plan. Documentation will become a part of the patient record. Documentation guidelines included eight factors involved in wound assessment as follows: wound location; staging; size measured in centimeters and involving length, width, and depth; tunneling/undermining measured using a Q-tip and noted in terms of clock directions; drainage or exudate; absence or presence of odor; wound color; surrounding skin condition assessed to determine overall viability or presence of outlying factors that may impede wound healing.

Patient #1
Review of Patient #1's medical record revealed an admission date of 2/20/19 with admission diagnoses including Sepsis and Acute Pulmonary Emboli.

Review of Patient #1's initial skin assessment on the 24 hour patient record (nurses' notes), dated 2/20/19, revealed the patient was noted to have red spots to the face area and 2 wounds to the back which were the former insertion sites of chest tubes that had been removed.

Further review revealed the following skin assessments:
2/22/19 and 2/23/19: no documentation referencing the wounds where the chest tubes had been removed.
2/24/19: generalized bruising- no description of the size, location, color, shape of the bruises. Further review revealed no documentation referencing the wounds where the chest tubes had been removed.
2/25/19: bruising/body - no description of the size, location, color, shape of the bruises. Further review revealed no documentation referencing the wounds where the chest tubes had been removed.
2/26/9: no documentation referencing bruising and no documentation referencing the wounds where the chest tubes had been removed.

In an interview on 3/19/19 at 2:09 p.m. with S2DON, she agreed patient skin assessments should be accurately documented.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 02/11/19 with diagnoses that included Septic Joint of the left knee, Diabetes mellitus, and Ulcer of the toe of the right foot.

Review of Patient #3's admission notes on 02/11/19 at 10:00 p.m. revealed wounds documented as follows:
Bilateral knee sutures on both side of knee with no drainage and odor and positive for pain; there was no documented evidence of the number of sutures, measurement of the suture line, and condition of the surrounding skin;
Right great toe wound with no documented evidence of wound color, drainage, odor, and pain;
Left great toe wound with no documented evidence of wound color, drainage, odor, and pain;
Bilateral heels cracked.

Review of S4NP's progress note dated 02/16/19 revealed "wound BLE mildly decreased."

Review of Patient #3's nursing notes from admission through 03/14/19 revealed no documented evidence of a wound/ulcer to the right foot.

Observation on 03/19/19 at 2:15 p.m. of Patient #3's skin revealed dry skin to the left leg with 4+ pitting edema to the ankle and foot with the 3rd and 4th toes with swelling with pink, taut skin. Further observation revealed the left great toe had an approx.. 2 cm broken area with no drainage noted. The left heel was cracked with old blood noted and slightly dusky in color. Right heel was cracked with old blood noted to the cracks.

In an interview on 03/19/19 at 1:45 p.m., S2DON indicated it (documentation of BLE wounds) had to be an error by S4NP, because the patient had no BLE wounds.

In an interview on 03/20/19 at 8:30 a.m., S2DON offered no explanation for the skin breakdown to the left great toe not being identified, reported to the physician, and orders for treatment obtained.

S4NP was unavailable to be interviewed during the survey due to being out of the country at the time of the survey.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 02/13/19 with diagnoses that included Sacral Decubitus Stage IV, Heel Ulceration, and Decubitus Ulcer of Coccyx Stage IV.

Review of Patient #4's "Admission Orders" dated 02/13/19 at 1:00 p.m. revealed an order for a wound care "ET Nurse" consult. Review of Patient #4's entire medical record revealed no documented evidence that an assessment by an ET nurse had been performed.

Review of Patient #4's "Admission Database: Wound Inspection" documented on 02/13/19 at 9:00 p.m. revealed the following wounds:
Back of right heel 3.5 cm by 4.0 cm unstageable, wound color black, flat, dry; drainage none; odor none; pain no;
Coccyx 12 cm by 13.2 cm by 1 cm Stage IV; wound color yellow, bed of wound red, some spots black; heavy drainage (no description documented); mild odor; no pain.
Review of Patient #4's nursing notes revealed no documented evidence of a measurement of the wounds since admit in accordance with hospital policy, as of 03/19/19, to determine whether the wound condition was improving or deteriorating.

Review of S4NP's progress note on 02/14/19 revealed the following skin assessment: unstageable sacral ulceration, 80% slough, some tunneling and undermining; needs debridement; moderately odorous; "I imagine after debridement that the wound would be a Stage IV." Review of progress notes by S4NP on 03/09/19, 03/10/19, and 03/11/19 revealed Patient #4's wound needed debridement. Review of the entire medical record revealed no documented evidence that the wound had been debrided.

Observation on 03/19/19 at 11:50 a.m. revealed S11RN performed wound care to the sacrum for Patient #4. Observation revealed dark reddish brown drainage around the anus. Further observation revealed the Stage IV wound was approximately 4"-5" across and approximately 3"-4" up-and-down. S11RN removed a small dressing that was on the left buttock that was covering a bony prominence that had a reddened area approximately 1" wide by 2" (Stage I).

In an interview on 03/19/19 at 11:50 a.m. while S11RN was performing wound care, S11RN indicated Patient #4's wound had not been debrided since this admit. She indicated "I have basic knowledge of wound care and I chart what I see, what I smell in my narrative." She further indicated she never measures the wound, and the only measurement of the wound is at admit.

In an interview on 03/19/19 at 1:45 p.m., S2DON confirmed no wound care nurse consult was done, and no wound measurement and assessment had been conducted since admit on 02/13/19.

S4NP was unavailable to be interviewed during the survey due to being out of the country at the time of the survey.

Patient #5
Review of Patient #5's medical record revealed an admission date of 3/6/19 for treatment of a pressure ulcer of the right hip (Stage IV).

Review of Patient #5's admission orders, dated 3/6/19 at 4:30 p.m., revealed the patient was admitted with an unstageable pressure ulcer of the right hip. Further review revealed no documented evidence referencing any other skin breakdown.

Additional review of Patient #5's physician's orders revealed an order, dated 3/17/19, to consult wound care specialists for evaluation of the patient's wounds.

Review of Patient #5's MAR revealed the following wound care treatments, started on 3/7/19 on the day shift (7:00 a.m. - 7:00 p.m.):
1.Clean right hip wound with wound cleanser, apply Santyl, cover with border daily and as needed.
2.Cleanse left hip wound with normal saline/wound cleanser, apply Santyl, cover with border gauze daily and as needed.
3.Right inner knee wound, cleanse with normal saline/wound cleanser, apply Santyl, cover with border gauze daily and as needed.
Additional review revealed wound care had been performed daily on all three of the wounds referenced on the MAR from 3/7/19 - 3/15/19.

Review of Patient 5's entire medical record revealed no documented evidence of an assessment of Patient #5's right hip wound, left hip wound or her right inner knee wound after an initial assessment where the wounds were measured on admission by S2DON. The medical record review was conducted on 3/19/19 which was 13 days after admission.

In an interview on 3/19/19 at 2:30 p.m. with S2DON, she confirmed Patient #5 had been admitted for wound care for pressure wounds. S2DON verified Patient #5 had an order for a consult with wound care specialists for wound evaluation and verified the consult had not been scheduled as of the time of the interview on 3/19/19 at 2:30 p.m. S2DON confirmed a skin assessment/body audit should have been performed on all admissions.




2) Failure of the RN to ensure daily quality control testing was performed on individual capillary blood glucose meters.
Review of the "True Metrix Self Monitoring Blood Glucose System Owner's Booklet", provided by S2DON, revealed the system is intended to be used by a single person and not to be shared and is intended for self-testing outside the body by people with diabetes at home as an aid to monitor the effectiveness of diabetes control. Further review revealed control tests should be performed occasionally as you use a vial of test strips, when opening a new vial of test strips, if results seem unusually high or low, if a vial has been left opened or exposed to extreme heat or cold or humidity, whenever a check on performance of the system is needed, and if meter damage is suspected. Further review revealed it is important to perform control tests with more than one level of control solution. Three levels of True Metrix Control Solution are available.

Review of the policy titled "Glucose Monitoring Quality Control", presented as a current policy by S1Adm, revealed the purpose of the policy is to ensure accuracy of results when utilizing the Precision PCx Blood Glucose Testing System to perform monitoring of the patient's blood glucose. Further review revealed quality control should be performed daily with each meter, each time a new lot of test strips is started, when test results contradict clinical symptoms, and when a blood glucose result is questionable. Further review revealed data will be maintained, and control sheets will be reviewed and stored for two years. There was no documented evidence the policy referred to the use of the "True Metrix Self Monitoring Blood Glucose System."

Patient #2
Review of Patient #2's medical record revealed an order on 03/01/19 at 8:00 p.m. for Insulin sliding scale in accordance with CBG pre-meal and at bedtime.

Patient #3
Review of Patient #3's medical record revealed an order at admit for Insulin sliding scale in accordance with CBG pre-meal and at bedtime.

Observation on 03/19/19 at 11:32 a.m. revealed S10RN performed a CBG assessment Patient #2. Continuous observation revealed S10RN did not perform a quality control test of the glucometer prior to using the glucometer to check Patient #3's CBG.

In an interview on 03/19/19 at 11:45 a.m., S11RN indicated they don't keep a log of quality checks of the glucometer daily before use. She further indicated they don't need to use a control solution for the individual glucometer that they use for each patient.

In an interview on 03/19/19 at 1:45 p.m., S2DON confirmed the glucometers are not being checked with control solution and logged when done. She confirmed the policy requires daily checks of the glucometers before use.





3) Failure of the RN to obtain patient admission orders from a licensed independent practitioner who was credentialed and privileged at the hospital.
Review of the "Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital', presented as the current rules and regulations by S1Adm, revealed all orders for treatment shall be in writing. All verbal and telephone orders shall be "read back" to the physician to assure correctness.

Patient #3
Review of Patient #3's "Admission Orders" dated 02/11/19 at 3:30 p.m. revealed the orders were documented as "RBO Admit Orders from Hospital B" and noted by S2DON.

Patient #4
Review of Patient #4's "Admission Orders" dated 02/13/19 at 1:00 p.m. revealed documentation by the RN that "orders rewritten for S3MedDir" with no documented evidence that the orders had been obtained from and read back to S3MedDir. Further review revealed "Facility Transfer Orders" from Hospital C were included in the admit orders.

In an interview on 03/19/19 at 1:45 p.m., S2DON indicated she gets the physician orders from the orders received from the referring hospital. She indicated when she documents VRBO she's verifying the orders from the referring hospital. She further indicated she doesn't read the orders to S3MedDir unless she has a question about the order. S2DON confirmed this system is how all patient orders are done. She further indicated she isn't getting admit orders from S3MedDir, because the patient is coming with their admit orders from the transferring hospital.

Patient #5
Review of Patient #5's medical record revealed an admission date of 3/6/19 for treatment of a pressure ulcer of the right hip (Stage IV).

Review of Patient #5's admission orders, dated 3/6/19 at 4:30 p.m., revealed the orders were signed by S2DON and had not been signed by a physician or a LIP as of 3/19/19 (date of record review). The orders had not been documented as verbal orders.

Review of Patient #5's H&P, dated 3/6/19 per S4NP, revealed the following, in part: CC/HPI: Patient #5 is unable to meaningfully contribute to her history due to presumed Dementia. There are limited medical records available in her transfer. Upon rounds the patient was found as a new admit on the unit from home. Apparently in February 2019 she was noted to have a new wound to the right hip noted by the NP who was performing house visits. It is unclear how she ended up at the LTAC. I am told by the director of nursing (S2DON) that the NP went to see the patient again at home and referred the patient for aggressive wound care in an inpatient setting. We'll closely follow the patient until we can determine exactly what her need for services are.

In an interview on 3/19/19 at 2:30 p.m. with S2DON, she confirmed she had written Patient #5's admission orders. She confirmed the orders had no physician/LIP signature as of 3/19/19. S2DON indicated she had written the admission orders based on the information provided by the referring NP who had been treating Patient #5 in the home. S2DON confirmed the NP had not been employed by the hospital and was not credentialed and privileged to admit patients. S2DON indicated she filled out the admission orders based on the expectations of the hospital's medical staff and not based on formal, approved standing orders.

Patient #8
Review of Patient #8's medical record revealed a 58 year old admitted on 11/18/18 with an admission diagnoses of severe debility, activity intolerance, impaired coordination, history of CVA, COPD exacerbation with asthma, DM, HTN, mitral valve replacement in 1990's, and long term Coumadin usage. She was discharged on 11/27/18.

On 03/19/19 at 1:50 p.m. in an interview with S2DON, she verified Patient #8's admission orders were based on the Pre-Admission history and assessment by S21LPN dated 11/08/18.


4) failure of the RN to implement physician orders for Accuchecks, weight, and labs and failure to ensure physician orders were obtained for all labs performed:

Review of the "Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital', presented as the current rules and regulations by S1Adm, revealed standing orders shall be instituted only after approval through the Continuous Quality Improvement Function of the Medical Staff. Such standing orders must be signed and dated by the responsible physician when utilized as required for all orders for treatment.

Patient #2
Review of Patient #2's medical record revealed a 36 year old with an admission date of 02/27/19 with an admission diagnosis of lung infection and intravenous antibiotics. Review of her medical history revealed Diabetes Mellitus.

Review of Patient #2's admission orders dated 02/27/19 did not reveal CBG orders. Further review of the Diabetic Record revealed CBG's checked pre-meal and at bedtime on 02/27/19 and 02/28/19 without an order. Further review revealed on 03/01/19 at 8:00 p.m. an order for blood glucose monitoring before meals and at bedtime with Novolog SSI PRN.

Further review of Patient #2's admission orders dated 02/27/19 ordered a weight on admission and weekly. The Graphic Flowsheet failed to document a weight between 02/28/19 and 03/11/19 (12 days).

On 03/18/19 at 1:50 p.m. S2DON verified the above findings.


Patient #3
Review of Patient #3's medical record revealed the admit order dated 02/11/19 at 3:30 p.m. included an order to administer Insulin in accordance with sliding scale CBG checks pre-meal and at bedtime. Further review revealed an order dated 02/11/19 at 4:50 p.m. to obtain a CBC,CRP, CMP, ESR, and Vancomycin trough once a week "per hospital discharge orders." Further review revealed an order on 02/19/19 at 2:57 p.m. to obtain daily weights at the same time and same method. Further review revealed an order on 02/21/19 at 7:15 p.m. to decrease Vancomycin to 1.5 grams every day at 4:00 p.m. IVPB and obtain Vancomycin trough with third dose stat and to obtain random Vancomycin levels every Monday and Thursday at 6:00 a.m. Further review revealed an order on 02/23/19 at 1:05 p.m. to change the Accuchecks to BID at 6:00 a.m. and 6:00 p.m. and an order on 02/23/19 at 6:00 p.m. to obtain a urinalysis and culture and PSA level in the morning. Further review revealed an order on 03/09/19 at 3:22 p.m. to obtain a stool culture for C. Diff., ova, WBC, and parasites.

Review of Patient #3's lab results revealed labs drawn 02/12/19 included T4, TSH, PSA, HgbA1C, Vitamin D with no documented evidence of orders received for these lab tests. Further review revealed no documented evidence of urinalysis and culture and PSA results that were ordered to be done on 02/24/19. Further review revealed no documented evidence that Vancomycin trough was done on Monday 03/04/19, and Thursday 03/07/19. There was no documented evidence of the time the trough was drawn on Monday 03/11/19. Further review revealed a Vancomycin trough was performed on 03/06/19 at 8:30 a.m. (Wednesday) with no documented evidence of an order for it to be drawn. There was no documented evidence a stool culture was obtained as ordered on 03/09/19.

Review of Patient #3's medical record revealed no documented evidenced Accuchecks were performed as ordered on 02/18/19 at 11:30 a.m., at 6:00 a.m. on 02/26/19, and at 6:00 a.m. and 6:00 p.m. on 03/14/19.

Review of Patient #3's "Graphic Vital Signs, Weights, I&O Flowsheet" revealed no documented evidence of a daily weight as ordered on 02/19/19, 02/20/19, 02/21/19, 02/22/19, 02/24/19, 02/25/19, 02/6/19, 02/28/19, 03/01/19, 03/02/19, 03/03/19 through 03/11/19, and 03/13/19 through 03/17/19.

In an interview on 03/20/19 at 8:30 a.m., S2DON indicated CBC, CMP, HgbA1C, ESR, PSA, TSH, T4, and Vitamin D are routine labs. She confirmed the labs were not written as routine labs in the medical record and that's why it looks like they don't have orders. She indicated daily weights for Patient #3 were not documented because the bed scales have to be zeroed out, and the patient doesn't want to get out of bed. She confirmed there's no documentation that the doctor was notified that weights were not being done daily. S2DON indicated the process for labs was the charge nurse was supposed to follow up to make sure the lab results were on the chart. The charge nurse was supposed to check against the duplicate lab slips. She confirmed she had not written an order to cancel the ordered C Diff until 03/19/19 (10 days since the order was written).

Patient #6
Review of Patient #6's medical record revealed an order on 03/06/19 at 6:15 p.m. for Vancomycin trough every Monday and Thursday at 5:00 a.m.

Review of Patient #6's medical record failed to reveal a Vancomycin trough, but did reveal laboratory results for CBC, CMP, sedimentation rate, and CRP without an order.

On 03/18/19 at 1:50 p.m. S2DON verified the above findings.


30984




39791

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current individualized and comprehensive nursing care plans. This deficient practice was evidenced by failure of the nursing staff to include all identified medical diagnoses and failure to include nursing interventions for 6 (#2, #3, #4, #7, #8, #10) of 9 (#1, #2, #3, #4, #5, 6, #7, #8, #10) sampled patients reviewed for care plans from a total sample of 30.

Findings:

Review of the hospital policy number PC-N02-N titled "Nursing Care Plan" revealed in part: the purpose is to provide a policy for the planning and providing of patient specific care according to the patient's individualized needs; addressing medical diagnosis, medications, nutrition, rehabilitation or other specialized care.


Patient #2
Review of Patient #2's medical record revealed a 36 year old with an admission date of 02/27/19 with an admission diagnosis of lung infection and intravenous antibiotics.
Review of her medical history revealed Diabetes Mellitus.

Review of Patient #2's orders revealed:
1. 02/27/19 at 8:30 p.m. admission orders for Insulin Glargine 15 units every AM SQ; Insulin Glargine 27 units every PM SQ; and Insulin Lispro sliding scale SQ (no detailed sliding scale for this date in medical record)
2. 03/01/19 at 8:00 p.m. an order for blood glucose monitoring ac (before meals) / hs (at bedtime) with Novolog SSI PRN.

Review of Patient #2's Diabetic Record dated 02/27/19 thru 03/18/19 revealed blood glucose results ranging between 32 and >500.

Review of Patient #2's current care plan revealed the following problems:
1. Actual anxiety related to hospitalization
2. Actual alteration in comfort
3. Actual and potential for infection
4. Alteration in elimination related to diarrhea
5. Actual nutrition risk factors identified

On 03/18/19 at 1:50 p.m. in an interview with S2DON verified Diabetes was not identified as a current problem to be addressed on the plan of care.

Patient #3
Review of Patient #3's medical record revealed he had a diagnosis of Diabetes Mellitus and was ordered to have CBG assessed before meals and at bedtime upon admission and changed to BID on 02/23/19 with physician orders for sliding scale Insulin based on the CBG results.

Review of Patient #3's medical record revealed documentation of his refusal to take medications as prescribed and to have his weight assessed daily.

Review of Patient #3's nursing care plan revealed no documented evidence a care plan was implemented for monitoring CBG and for noncompliance with treatment.

In an interview on 03/20/19 at 8:30 a.m., S2DON confirmed Patient #3 did not have a nursing care plan developed and implemented for Diabetes and noncompliance with treatment.

Patient #4
Review of the policy titled "Anticoagulation Therapy", presented as a current policy by S1Adm, revealed no documented evidence that the policy addressed the need to develop and implement a nursing care plan for the potential risk for bleeding.

Review of Patient #4's progress note documented by S4NP on 02/14/19 revealed he was on Coumadin. Further review revealed an order on 03/17/19 at 6:00 p.m. to hold Coumadin due to the patient having a large amount of rectal bleeding noted.

Review of Patient #4's nursing care plan revealed no documented evidence a care plan was developed and implemented for the potential risk for bleeding related to the administration of Coumadin.

In an interview on 03/20/19 at 8:30 a.m., S2DON confirmed Patient #4 did not have a nursing care plan developed for the potential risk for bleeding.

Patient #7
Review of Patient #7's medical record revealed a 71 year old admitted on 11/18/18 with an admission diagnosis of impaired mobility/gait and diabetic peripheral neuropathy. He was discharged on 11/27/18.
Review of his medical history revealed Diabetes Mellitus, Hypertension, and Coronary Artery Disease.

Patient #7's care plan did not reflect his diagnoses of Diabetes or Hypertension.

Patient #8
Review of Patient #8's medical record revealed a 58 year old admitted on 11/18/18 with an admission diagnoses of severe debility, activity intolerance, impaired coordination, history of CVA, COPD exacerbation with asthma, DM, HTN, mitral valve replacement in 1990's, and long term Coumadin usage. She was discharged on 11/27/18.

Review of Patient #8's current care plan revealed the following problems:
1. Knowledge deficit related to disease process
2. Alteration in air exchange related to exertion during activity
3. Alteration in elimination related to stress incontinence
4. Potential for injury/fall related to unsteady gait and weakness
5. Self-care deficit related to decreased strength and endurance

On 03/18/19 at 1:50 p.m. in an interview with S2DON verified Diabetes, Coumadin usage, and HTN were not identified as current problems to be addressed on the plan of care.

Patient #10
Review of Patient #10's medical record revealed a 55 year old admitted on 11/28/18 with an admission diagnosis of unsteady gait, debility, pain, and diabetes.

Review of Patient #10's care plan revealed the following problems:
1. Knowledge deficit related to perceived health status
2. Alteration in mental status related to orientation and medication
3. Alteration in elimination related to incontinence
4. Potential for physical injury/fall risk related to unsteady gait, weakness, and altered mental status
5. Self-care deficit related to decreased strength, endurance, and altered mental status
6. Potential nutrition risk factors identified related to

On 03/18/19 at 1:50 p.m. in an interview with S2DON verified Diabetes was not identified as a current problem to be addressed on the plan of care.




39791

Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other personnel in accordance with the specialized qualifications and competency of the nursing staff available as evidenced by failure to have documented evidence of orientation and competency evaluation of nursing skills for 2 (S2DON, S10RN) of 4 (S2DON, S9RN, S10RN, S11RN) RN personnel files reviewed and 1 (S12HK) of 1 housekeeper personnel file reviewed for orientation and evaluation of competency.

Findings:

Review of the personnel files of S2DON, S9RN, S11RN, and S12HK revealed no documented evidence that each had received orientation and had an evaluation of competency in performing job skills related to their employment.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the above-listed personnel files had no evidence that each employee had received orientation to their job and had been evaluated for competency in performing their job skills.

38777


Based on record review and interviews, the hospital failed to ensure all drugs and biologicals were administered as ordered by the physician and according to acceptable standards of practice for 4 (#3, #9, #11, #13) of 11 (#1 - #8, #9, #11, #13) patient records reviewed for medication administration from a sample of 30 patient records.

Findings:

Review of the policy titled "Medication Administration", presented as a current policy by S1Adm, revealed medications are given at the time ordered or within 60 minutes before or 60 minutes after the time designated.

Patient #3
Review of Patient #3's physician orders revealed an order on 02/11/19 at 3:30 p.m. to administer Levimir Insulin 10 units subcutaneously every evening. Further review revealed an order on 02/19/19 at 2:57 p.m. for Lasix 40 mg IV daily for 3 days, 1st dose now.

Review of Patient #3's MARs and nursing notes revealed Patient #3 refused Levimir Insulin on 02/23, 02/25, 02/26, 02/27, 02/28, 03/02, 03/03, 03/04, 03/07, 03/08, 03/09, 03/10, 03/11, and 03/13 with no documented evidence the physician or NP was notified. Further review revealed Lasix 40 mg IV, ordered to be given now on 02/19/19 at 2:57 p.m., was not administered until 8:36 p.m. (5 hours 39 minutes after it was ordered). The 2nd dose was refused by the patient on 02/20/19. There was no documented evidence the physician was notified of the delay of administering Lasix on 02/19/19 and that the 2nd dose was not administered.

Patient #9
Review of Patient #9's medical record revealed an order on 11/22/18 at 10:21 a.m. to give Singulair 10 mg by mouth every HS, give the first dose now, and Mucinex 600 mg one by mouth BID.

Review of Patient #9's MAR and nursing notes revealed Singulair and Mucinex was was not administered on 11/22/18 as ordered due to it not being available. Both medications were not administered until 11/23/18.

In an interview on 03/20/19 at 8:30 a.m., S2DON indicated S3MedDir was informed that Patient #3 was refusing Levimir, but the nurses didn't document the notification in the medical record. She confirmed Singulair and Mucinex was not administered as ordered for Patient #9. She further indicated medications shouldn't be "not available." She indicated pharmacy delivers about 3:00 p.m. She further indicated the physician should be notified if a medication is not available.

Patient #11
Review of Patient #11's medical record revealed an admission date of 11/14/2018 with diagnoses of malaise, functional decline, myopathy, and dementia. Further review revealed the patient was discharged on 11/28/18.

Review of Patient #11's physician's orders revealed an admission order, written as a verbal order read back on 11/13/2018, for Cosopt eye drops (used for treatment of glaucoma) - 1 drop twice daily in both eyes.

Review of Patient #11's MAR revealed Cosopt eye drops were to be administered at 10:00 a.m. and 10:00 p.m. Further review revealed no documented evidence that the eye drops had been administered and no documented reason for not administering the eye drops as ordered for the 10:00 p.m. dose on the following dates: 11/15/18, 11/16/18 and 11/22/18.

Patient #13
Review of Patient #13's medical record revealed an admission date of 11/29/18 with diagnoses of late effects hemorrhagic CVA, spastic diplegia, cerebral palsy, right hemiparesis, and Wernicke aphasia. Further review revealed the patient was discharged on 12/12/18.

Review of Patient #13's physician's orders revealed the following orders:
Amlodipine Besyl - 10mg tab PO daily, hold if SBP less than 100, DBP less than 55, pulse less than 50;
Lisinopril - 40 mg PO daily, hold SBP less than 100, DBP less than 55 and pulse less than 50;
Labetalol - 200 mg PO BID, hold SBP less than 100, DBP less than 55 and pulse less than 50.

Review of Patient #13's MAR revealed the following ordered medications and times of administration:

Amlodipine Besyl 10 mg tab was to be administered daily at 10:00 a.m. The patient's blood pressure and pulse were to have been documented with each dose.

Further review of the MAR revealed the patient's blood pressure and/or pulse were not documented on the following dates when the medication was administered at 10:00 a.m.:
12/2/18: no pulse;
12/3/18: no pulse;
12/5/18: no pulse;
12/6/18: no BP and no pulse;
12/7/18: no BP and no pulse; and
12/9/18: no BP and no pulse.

Lisinopril - 40 mg tab was to be administered daily at 10:00 a.m. The patient's blood pressure and pulse were to have been documented with each dose.

Further review of the MAR revealed the patient's blood pressure and/or pulse were not documented on the following dates when the medication was administered at 10:00 a.m.:
12/3/18: no BP and no pulse;
12/5/18: no pulse;
12/6/18 no BP and no pulse;
12/7/18 no BP and no pulse; and
12/9/18 no BP and no pulse.

Labetalol HCL - 100 mg tab was to be given at 10:00 a.m. Further review of the MAR revealed the patient's blood pressure and/or pulse were not documented on the following dates when the medication was administered at 10:00 a.m.:
12/3/18: no BP and no pulse;
12/5/18: no pulse;
12/6/18: no BP and no pulse;
12/7/18: no BP and no pulse; and
12/9/18: no BP and no pulse.

Labetalol HCL - 100 mg tab to be given at 10:00 p.m. Further review of the MAR revealed the patient's blood pressure and/or pulse were not documented on the following dates when the medication was administered at 10:00 p.m.:
12/2/18: no pulse;
12/3/18: no BP and no pulse;
12/4/18: no BP and no pulse;
12/5/18: no pulse;
12/6/18: no BP and no pulse;
12/7/18: no BP and no pulse; and
12/8/18 no BP and no pulse.

Review of Patient #13's MAR, Nurses' Notes, and Graphic Sheet revealed no documented evidence of the above referenced missing vital sign assessments.

In an interview on 3/20/19 at 2:40 p.m. with S1Adm, she confirmed the above findings.

Based on record review and interview, the hospital failed to ensure a policy was in place for a patient (or his or her caregiver/support person where appropriate) to self -administer the patient's own medications brought into the hospital, failure to ensure the prescribing practitioner had written an order permitting self-administration of a home medication by the patient's care giver, and failure to order identification and visual inspection of the home medication's integrity, by the physician, prescribing practitioner, pharmacist, or nurse, prior to self-administration for 1(#8) of 1 total patient reviewed who was receiving home medications while hospitalized from a total patient sample of 30.

Findings:

Requests for hospital policies regarding home medication or self-administration of a home medication were made on
3/19/19 and none were provided as of survey team exit on 3/21/19.

Review of Patient #8's medical record revealed an admission date of 11/18/18 with admission diagnoses of severe debility, history of CVA, mitral valve replacement in 1990's, and long term Coumadin usage. She was discharged on 11/27/18.

Review of Patient #8's orders revealed no orders indicating the patient could take home medications (Coumadin), no orders to indicate the patient may self-administer medication, and no order requiring identification and visual inspection of the home medication's integrity, by the physician, prescribing practitioner, pharmacist, or nurse, prior to self-administration.

Review of Patient #8's discharge summary dated 11/27/18 revealed the folllowing: "Of note, she (Patient #8) was also on the wrong dose of Coumadin as per medical records, but the patient endorsed to me that she had been taking her own Coumadin in the room ....The patient's INR at the time of discharge was 1.2. The patient was informed of the need to double up on her Coumadin and to report to her physician within the next 2 days for further management."

Review of Patient #8's coagulation laboratory report dated 11/20/18 at 10:17 a.m. revealed an INR of 1.5 (0.8 - 1.2 normal values). Further review revealed a note indicating for patients with prosthetic heart valves an INR of 2.5 - 3.5 is recommended.

Review of Patient #8's MAR revealed the following: Coumadin 2 mg tablet take 1 by mouth daily. Further review revealed the following entry on 11/18/18: "took own". Coumadin administration was not documented as having been given on 11/21/18 or 11/26/18 and no reason was documented as to why the medication may not have been given.

On 03/19/19 at 3:00 p.m. S2DON verified Patient #8 had no physician's orders to allow self-administration of home medications (specifically Coumadin).

In an interview on 3/20/19 at 4:00 p.m. with S1Adm, she confirmed the hospital had no established policies/procedures on self-administration of home medications because that was not a practice to be performed at this hospital.

Based on record review, observation, and interview the hospital failed to ensure patient medical records were promptly completed, readily accessible, and protected from damage or loss. This deficient practice was evidenced by:
1) failure to ensure all medical records were completed by physicians/LIPs within 30 days after discharge as evidenced by S3MedDir having 9 medical records that were over 30 days delinquent and 3 medical records that were over 60 days delinquent;
2) failure to ensure patient medical records were easily retrieved and readily accessible as evidenced by having no access to patient records from 11/1/17 - 9/21/18; and
3) failure to ensure all medical records were stored in secured locations and protected from damage or loss.

Findings:


1) Failure to ensure all medical records were completed within 30 days after discharge.

Review of the Medical Staff By-laws revealed the following, in part: if the medical record is incomplete 30 days after discharge, a written notice shall be sent to the physician by the CEO notifying him that he has 7 days to complete the medical records or his admitting privileges will be suspended.

Review of a manual count of delinquent medical records, performed by S1Adm, revealed S3MedDir had 9 medical records that were over 30 days delinquent and 3 medical records that were over 60 days delinquent.

In an interview on 3/18/19 at 2:00 p.m. with S1Adm,she confirmed the above referenced findings.

2) Failure to ensure patient medical records were easily retrieved and readily accessible.

On 3/18/19 a list of discharged patients for the last year was requested on survey team entry.

On 3/18/19 at 2:00 p.m. S1Adm revealed she had no access to patient medical records from 11/1/17 - 9/24/18 and could not provide any requested discharged patient records from that time period.

3) Failure to ensure all medical records were stored in secured locations and protected from damage or loss.

On 03/19/19 at 10:10 a.m. an observation of the medical records department revealed a sprinklered room, which contained 70 boxes of medical records that were uncovered on the floor. S1Adm, who was present at the time of the observation, confirmed the records were not protected and replied there was nothing she could do about protecting the records.

Based on interviews, the hospital failed to develop a system for coding and indexing medical records that allowed timely retrieval of medical records.

Findings:

On 03/18/19 at 2:00 p.m. S1Adm revealed she did not have a system in place for coding and indexing patient records by diagnosis and/or procedure. She confirmed she was unable to provide a list of patients indexed by specific diagnosis and/or procedure. When asked, for example, if she could provide a list of Diabetic patients she replied ,"No."

Based on record reviews and interviews, the hospital failed to ensure all clinical records, including physician/NP progress notes and orders, were dated and timed when written or authenticated. This deficient practice was evidenced by failure to have progress notes and orders with no documented evidence of the date and/or time the note or order was written or authenticated for 6 (#1, #3, #4, #5, #8, #9) of 9 (#1- #9) patient records reviewed for dating, timing, and authentication of entries from a sample of 30 patients.

Findings:

Review of the "Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital", presented as the current rules and regulations by S1Adm, revealed all clinical entries in the patient's medical record shall be accurately timed, dated, and authenticated.

Patient #1
Review of Patient #1's medical record revealed dictated progress notes signed by S3MedDir and/or S4NP, dated 2/22/19, 2/28/19, 3/1/19, and 3/2/19. The referenced progress notes had no documented evidence of the time the notes were authenticated.

Patient #3
Review of Patient #3's medical record revealed dictated progress notes signed by S3MedDir, S4NP, and/or S7NP and dated 02/16/19, 02/17/19, 02/19/19, 02/20/19, 02/21/19, 02/24/19, 02/25/19, and 03/09/19 had no documented evidence of the time the notes were authenticated.

Review of physician orders dated 02/11/19 (2 orders), 02/14/19, 02/19/19, 02/20/19, 02/21/19 (2 orders), 02/23/19 (2 orders), 02/24/19 (2 orders), and 03/09/19 revealed no documented evidence of the date and time the orders were authenticated by S3MedDir.

Patient #4
Review of Patient #4's medical record revealed a progress note documented by S4NP on 02/14/19 had no documented evidence of the date and time S4NP authenticated the note. Further review revealed progress notes documented by S7NP on 03/09/19, 03/10/19, and 03/11/19 had no documented evidence of the date and time S7NP authenticated the notes.

Patient #5
Review of Patient #5's medical record revealed a progress noted documented by S7NP on 3/6/19. Further review revealed had no documented evidence of the time S7NP authenticated the note.

Patient #8
Review of Patient #8's medical record revealed progress notes documented by S3MedDir and S4NP on 11/22/18 and 11/26/18 had no documented evidence of the dated and time S3MedDir and S4NP authenticated the notes.

Patient #9
Review of Patient #9's physician/NP orders revealed orders dated 11/21/18 (2 orders) and 11/22/18 had no documented evidence of the date and/or time the orders were authenticated by S3MedDir.

In an interview on 03/20/19 at 8:30 a.m., S2DON confirmed all clinical record entries were supposed to be timed and dated when written or authenticated.


30984




39791

Based on record reviews and interviews, the hospital failed to ensure all records contained a medical H&P examination completed and documented no more than 30 days before or 24 hours after admission as evidenced by failure of the physician to time and date his authentication on the H&P to be able to determine that the H&P was completed and in the medical record within 24 hours of admission for 5 (#2, #3, #8, #9, #10) of 10 (#1 - #10) patient records reviewed for H&Ps from a sample of 30 patients.
Findings:

Review of the "Rules and Regulations of the Medical Staff of St. Theresa Specialty Hospital", presented as the current rules and regulations by S1Adm, revealed each patient shall receive a H&P examination completed no more than 24 hours after admission, and documentation must be placed in the patient's medical record within 24 hours of admission.

Patient #2
Review of Patient #2's medical record revealed she was admitted on 02/27/19. Further review revealed a H&P examination was documented on 02/28/19and signed by S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 02/12/19. Further review revealed a H&P examination was documented on 02/12/19 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/18/19. Further review revealed a H&P examination was documented on 11/19/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #9
Review of Patient #9's medical record revealed she was admitted on 11/21/18. Review of her H&P revealed it was performed on 11/22/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

Patient #10
Review of Patient #10's medical record revealed she was admitted on 11/28/19. Further review revealed a H&P examination was documented on 11/29/18 and signed by S3MedDir and S4NP with no documented evidence of the time the examination was performed to be able to determine that the examination was performed within 24 hours of admission.

A telephone call was attempted to reach S3MedDir on 03/20/19 at 12:45 p.m. When no answer was received, a message was left on his cell phone and office phone requesting that he contact the surveyors at the hospital. No return call was received from S3MedDir as of the end of the day on 03/20/19.

In an interview on 03/20/19 at 8:30 a.m., S2DON indicated without a time documented on the H&P, she couldn't say whether the H&P was conducted within 24 hours of admission.





39791

Based on record review and interview, the hospital failed to ensure medical records included a properly executed informed consent for admission and treatment, authorization to release information and assignment of insurance benefits. This deficient practice was evidenced by informed consents for admission and treatment, authorization to release information and assignment of insurance benefits were not completed for 8 (#12, #13, #14, #15, #16, #17, #18, #29) of 8 discharged patients reviewed for properly executed informed consents.

Findings:

A review of the medical records for the following discharged patients failed to reveal a signed consent for admission and treatment, authorization to release information and assignment of insurance benefits.
a) Patient # 12 who was admitted 11/13/18 and discharged 11/21/18.
b) Patient # 13 admitted 11/29/18 and discharged 12/12/18.
c) Patient # 14 was admitted 11/8/18 and discharged 11/20/18.
d) Patient #15 admitted 11/8/18 and discharged 11/20/18.
e) Patient #16 admitted on 11/8/18 and discharged on 11/20/18.
f) Patient # 17 admitted on 11/13/18 and discharged on 11/28/18.
h) Patient #18 admitted 11/14/18 and discharged 11/17/18, readmitted 11/21/18 and discharged on 12/5/18.
i) Patient #26 admitted 1/3/19 and discharged 1/23/19.

On 3/20/19 at 2:40 p.m. S1Adm verified the above findings.

Based on contract review, organizational chart review, and interview, the hospital failed to ensure Radiological Services were under the direction of a Radiologist. This deficient practice is evidenced by failure of the Governing Body to appoint a Radiologist to serve as Director of the hospital's contracted Radiological Services.

Findings:

Review of the hospital's on location x-ray services revealed the services were provided via contract with an area mobile x-ray company.

Review of the hospital's organizational chart revealed no documented evidence of an appointed Radiologist to serve as Director of the hospital's contracted Radiological Services.

In an interview on 3/19/19 at 10:00 a.m. with S1Adm, she confirmed the hospital's on location x-ray services were provided via contract with an area mobile x-ray company. S1Adm further confirmed the hospital's Governing Body had not appointed S20Rad to serve as the Director of the hospital's contracted Radiological Services.

Based on interview, the hospital failed to ensure it had a contractual agreement with a certified laboratory as evidenced by failure to provide a contract with Company A for laboratory services provided and to have documented evidence that Company A had a current CLIA certificate.

Findings:

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated she didn't have a contract to present with Company A for lab services being provided by Company A. She further indicated she didn't have evidence of a current CLIA certificate for Company A for review by the surveyors.

Based on record reviews and interview, the hospital failed to have policies and procedures developed that addressed the responsibility of the hospital related to potentially HIV or HCV infectious blood or blood components administered to a patient as evidenced by having no contract with a blood bank presented for review and failure to have policies and procedures developed that addressed the hospital's responsibility related to the administration of potentially HIV or HCV infectious blood or blood components administered to patients.
Findings:

Review of policies and procedures presented by S1Adm revealed no documented evidence that policies and procedures had been developed that addressed the hospital's responsibility if potentially HIV or HCV infectious blood or blood components were administered to a patient.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the hospital did not have policies related to the hospital's responsibility if patients were administered potentially HIV or HCV infectious blood or blood components.

Based on record reviews, observations, and interviews, the hospital failed to ensure individual patient nutritional needs were met in accordance with recognized dietary practices. This deficient practice is evidenced by failure of the hospital to have a system in place to provide meals for 2 current inpatients (#2, #3) on special diets, 2 current inpatients (#1, # 5) on regular diets, and all future patients admitted while the kitchen is closed due to issuance of a cease and desist for use of all current cooking equipment by the State Fire Marshall on 3/19/19 at 3:27 p.m. The cease and desist for all cooking equipment left the hospital with no means for provision of meal service for the dinner service on 3/19/19 and all future meal services for the current inpatients for the duration of the kitchen closure.

Findings:

Review of the hospital's inpatient Dietary Sheet revealed the following: The hospital's current census was 5. Further review revealed Patients #1 and #5 were receiving regular diets, Patient #2 was on a diabetic diet, and Patient #3 was on a cardiac, low fat, low sodium, low cholesterol, diabetic diet. Patient #4 was NPO and receiving Jevity 1.5 at 65 ml/hr with Juven twice a day. S13DM (Dietary Manager) provided the list and verified it was current.

Review of State Fire Marshall report documentation, completed during an onsite inspection on 3/19/19, revealed a grease fire had occurred in the kitchen, on the front left burner of the range a few weeks prior to the inspection. The suppression system had not activated and was not manually activated.

On 3/19/19 at 11:40 a.m. an observation was made of the hospital's kitchen and food preparation areas/equipment. There was no signage or any indication noted in the kitchen to alert staff that the front left burner of the stove was unsafe for use.

On 3/19/19 at 3:27 p.m. a cease and desist for use of all current cooking equipment was issued by the State Fire Marshall.

In an interview on 3/19/19 at 4:55 p.m. with S1Adm, she reported she would have to attempt to either order out or get meals from Hospital A to provide meals for the patients while the kitchen was closed. S1Adm further indicated securing a contract with a provider for provision of patient meals "might take a while."

In an interview on 3/20/19 at 1:47 p.m. with S17Diet (Dietician), she confirmed she was the hospital's dietician. She reported she performed nutritional assessments on the patients and approved the hospital's menus for used for preparation of all inpatient diets (both regular and special diets. S17Diet indicated she had not been informed of the kitchen being closed due to a cease and desist order from the State Fire Marshall. S17Diet further indicated she had not been aware the hospital's kitchen staff was unable to prepare any inpatient meals.

In an interview on 3/20/19 at 4:00 p.m. S1Adm reported the patients on regular diets had been provided meals from a fast food sandwich company and a fast food chicken company for meal service since the kitchen had been closed.

Based on record review and interview, the hospital failed to ensure the UR committee included two members who were doctors of medicine or osteopathy. This deficient practice was evidenced by failure to have an established UR committee that included two physician members who were doctors of medicine or osteopathy.

Findings:

Review of the UR documentation presented by S1Adm revealed no documented evidence of an established UR committee that included two physician members who were doctors of medicine or osteopathy.

In an interview on 3/19/19 at 9:30 a.m. with S1Adm, she confirmed formation of the hospital's UR committee, including appointment of two physician members, had not been completed as of 3/19/19.

Based on observations, review of hospital documentation, and interviews , the hospital failed to ensure the overall hospital environment was maintained in a manner to ensure the safety and well being of patients, staff, and visitors. This deficient practice was evidenced by failure to maintain a clean and safe environment due to having multiple breaches in the quality and safety of the environment of care.

Findings:

The hospital is licensed for 42 beds and the inpatient census was 5 on 3/19/19.

During an observation of the hospital's physical plant from 10:00 a.m. to 3:30 p.m. on 3/19/2019, conducted by the State Fire Marshal, the following findings were noted:

Interior Findings:

Fire Alarm System/Sprinklers:

a. The fire alarm system had been yellow tagged on 9/15/2018 for the tamper on the sprinkler riser needing to be replaced. It was also observed that throughout the entire facility ceiling tiles were missing that could prevent the smoke detectors from operating properly.

In an interview with S1Adm, during the observation, she revealed she was not aware that the fire alarm system had been yellow tagged and that the missing ceiling tiles could affect the fire alarm system.

b.throughout the facility was numerous sprinkler heads were corroded, dirty, and escutcheon plates were missing.

c. throughout the facility ceiling tiles were missing that could result in the sprinkler system not operating as designed.

In an interview with S1Adm, during the observation, she revealed she was not aware that the annual inspection had not been properly conducted on the automatic sprinkler system and that sprinkler heads were corroded, dirty, missing escutcheon plates, and that the missing ceiling tiles could cause the sprinkler system to not function as designed.

Fire Extinguishers:

All extinguishers in the hospital were last inspected in 9/2017. It was observed that multiple extinguishers appeared to be missing due to the empty fire extinguisher mounts. Also three fire extinguishers were present in the kitchen fully discharged due to use on a kitchen fire weeks prior.

In an interview with S1Adm, during the observation, she revealed she was not aware that the annual and monthly inspection on the fire extinguishers had not been conducted.

Deficient Smoke Barriers:

a.Observations were made of missing ceiling tiles, penetrations, and gaps were present in smoke barriers throughout the hospital.

b.Further observation revealed there were missing ceiling tiles and penetrations in the walls on both the side of the corridor and patient room throughout the hospital.

In an interview with S1Adm, during the observation, she revealed she was not aware of the penetrations in the corridor walls that would allow the transfer of smoke from one room to another. S1Adm further revealed she was not aware of unsealed penetrations and gaps in the smoke barriers.

Fire Watch: Due to the above referenced findings related to the Fire Alarm System and Sprinkler System and multiple Life Safety Code issues, the State Fire Marshal placed the hospital on a Fire Watch to remain in effect until the Office of the State Fire Marshal has conducted an inspection rescinding the Fire Watch.

Kitchen Findings:

The kitchen suppression system was last inspected and serviced in 2017. It was also observed that the cooking equipment had been moved from the original designed locations for the suppression system to operate correctly. It was also noted that food was on the front left burner of the range cooking with no one present in the kitchen area.

Interview with one of the staff members and S1Adm, during the observation, revealed the hospital had a cooking (grease) fire a few weeks prior. The fire was located on the front left burner of the range. The kitchen suppression system was not activated and the staff did not manually activate the system. Staff responded to the fire and three ABC fire extinguishers were utilized to suppress the fire. A K-class extinguisher was present next to the hood, however the staff did not know to use it for grease fires.

In the interview with S1Adm, during the observation, she further revealed she had not been was aware the semi-annual inspection was not conducted on the hood suppression system and that the appliances in the kitchen were not covered properly by the hood suppression system.

On 3/19/19 at 3:27 p.m. the hospital's kitchen was closed by the State Fire Marshal due to issuance of a cease and desist for use of all current cooking equipment. The cease and desist for all cooking equipment was to remain in effect until the kitchen suppression system has been provided with a current inspection, service, maintenance, and inspection by the State Fire Marshal's Office granting use of the system.


Door Issues:

a.Throughout the entire facility doors with closures were observed to be held open by wooden and metal wedges.

b. Numerous areas being used for storage and other hazardous areas had doors that were not provided with automatic or self-closing devices.

c. Multiple corridor doors equipped with magnetic hold devices that can no longer connect with the contact to hold the door opened as designed.

d. Multiple hazardous areas throughout the facility did not have doors provided with self-closing or automatic closing hardware. This included previous patient rooms now being used for storage and the physical therapy room being used for oxygen storage.

In an interview on 3/19/19 at 3:30 p.m. with S1Adm, she reported she had not been aware that the doors were being propped open, needed closures, and that the magnetic holds were not making contact with the doors.
S1Adm, further reported she had not been aware that the doors to the hazardous areas were required to self-close and latch in the frame.

Emergency/Exit Lighting:

Almost all emergency lights were non-functional. Multiple emergency lights were also observed to have had the mounting device broken and were hanging by the lights' wiring. Further observation revealed the exit signage was not provided with continuous illumination and emergency lighting.

In an interview on 3/19/19 at 3:30 p.m. with S1Adm, she reported she had not been aware that the emergency lighting throughout the facility was non-functional and the exit signs were not illuminated.

Oxygen Storage:

Oxygen cylinders, in the oxygen storage room near the nurses' station, were unsecured. One cylinder had been placed in a small trash like container and had already fallen over.

In an interview during the observation, with S1Adm, she reported she had not been aware that the oxygen cylinders were not being properly secured.


Door Malfunctions:

During the record review and hospital observation, no documentation was provided for the State Fire Marshal, for door inspections. It was observed that multiple corridor doors did not fully open, could not come in contact with magnetic hold, and the panic hardware did not function properly.

In an interview with S1Adm, during the observation, she revealed she was not aware that the doors were not being inspected and maintained properly.

Electrical System Testing:

No documentation for any testing and maintenance of the hospital's electrical systems was provided to the State Fire Marshal.

In an interview with S1Adm, during the observation, she revealed she was not aware that the testing, maintenance, and documentation for the electrical systems was not being performed.

Generator Testing:

No reports indicating weekly or 30 minute load tests had been performed and documented for the generator could be provided for review by the State Fire Marshal.

In an interview with S1Adm, during the observation, she revealed she was not aware that testing, inspection, and documentation had not been performed/documented for the emergency generator.


Exterior Findings:

a. Multiple ramps and stairs from marked exits had ground and concrete that had collapsed. The collapse in these areas caused drop offs, unleveled walking surfaces that obstructed egress. The sinking/collapsed areas had also damaged the handrails and guardrails.

b.One of the back exits had a single covered parking spot that was elevated with no ramp or stair provided.

c. Exit door from the cafeteria had slide bolts added to both of the double doors. In the receiving area the fenced in portion had the entrance gate pad locked.


In an interview on 3/19/19 at 3:30 p.m. with S1Adm, she confirmed she was aware that multiple ramps and stairs out of marked exits in the corridor were obstructed and were not to full instant use and affected egress. S1Adm also reported she was not aware that the slide bolts and the pad lock was being utilized.

Based on record reviews and interview, the hospital failed to ensure a person or persons was designated as infection control officer(s) to develop and implement policies governing control of infections and communicable diseases as evidenced by failure to have documented evidence of experience and training in current infection control practice for 2 (S1Adm, S2DON) employees designated as infection control officers.
Findings:

Review of the personnel file of S1Adm and S2DON revealed no documented evidence of prior experience in implementing an infection control program and training in current infection control practices.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated she and S2DON had been responsible for the infection control program. She confirmed that neither she nor S2DON had prior experience or had current training in infection control practice to be qualified to function as Infection Control Officers.

Based on observations, record reviews, and interviews, the infection control officer failed to develop and implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

1) Failing to implement HAI risk mitigation measures as evidenced by observation of breaches in hand hygiene on 03/19/19;
2) Failing to maintain a sanitary physical environment as evidenced by improper techniques for food sanitation, breaches in techniques for cleaning and disinfecting environmental surfaces, unsuccessful techniques for pest control, having stained and missing ceiling tiles and stained toilets in patient bathrooms as observed during an environmental tour conducted on 03/18/19 at 8:50 a.m. and 10:50 a.m.
3) Failing track, measure, analyze, and trend infections as evidenced by having the tracking report and log void of documentation;
4) Failing to implement hospital staff-related measures as evidenced by (a) failure to have current TB test results in accordance with the OPH guidelines for 3 (S2DON, S10RN, S18RT) of 6 (S1Adm, S2DON, S10RN, S11RN, S12HK, S18RT) employee/contract staff and 2 (S3MedDir, S7NP) of 2 physician/nurse practitioner personnel/credentialing files reviewed for TB test results and (b) failure to have documented evidence of new employee and regular update training in preventing and controlling HAI and methods to prevent exposure to and transmission of infections and communicable diseases for 9 (S1Adm, S2DON, S9RN, S10RN, S11RN, S12HK, S13DM, S17Diet, S18RT) of 9 employee/contract staff personnel files reviewed for infection control training; and
5) Failing to perform active surveillance to monitor compliance with hand hygiene practices by staff as evidenced by failure to provide documentation that active surveillance of hand hygiene practice had been performed and was maintained
6) Failing to ensure expired medical supplies had been removed from inventory enabling expired medical supplies to be available for use.

Findings:

1) Failing to implement HAI risk mitigation measures related to breaches in hand hygiene:

Observation on 03/19/19 at 8:38 a.m. on the inpatient unit revealed S12HK entered Room "c" with gloves on to place a trash liner in the trash receptacle. Continuous observations revealed she exited the room wearing the contaminated gloves, walked to the housekeeping cart, and rolled the cart with contaminated gloves from the nursing station area to the entrance of the west hall (hall containing patient rooms being used). S12HK failed to remove her contaminated gloves and perform hand hygiene before touching the housekeeping cart.

Observation on 03/19/19 at 8:40 a.m. revealed S11RN entered Room "c" to draw a blood sample. She gloved, drew the blood sample, discarded the syringes in the sharps box, removed her gloves, and re-gloved without performing hand hygiene.

Observation on 03/19/19 at 8:52 a.m. revealed S12HK was cleaning Room "b" with gloved hands. Continuous observation revealed she returned to the housekeeping cart twice to obtain a pen and supplies with contaminated gloves. S12HK failed to remove her contaminated gloves and perform hand hygiene before touching the housekeeping cart to obtain supplies.

Observation on 03/19/19 at 11:32 a.m., S10RN was observed performed a CBG finger stick. She removed the right glove after performing the procedure and walked to the medication cart where she re-donned a right glove without performing hand hygiene.

Review of the CDC's "Guideline for Hand Hygiene in Health-Care Settings" revealed hands should be decontaminated after having direct contact with patients, after contact with a patient's intact skin, after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings, after contact with inanimate objects in the immediate vicinity of the patient, and after removing gloves.

In an interview on 03/19/19 at 8:57 a.m., S12HK confirmed the above breaches in hand hygiene.

In an interview on 03/19/19 at 8:58 a.m., S11RN confirmed she didn't perform hand hygiene between glove use.

In an interview on 03/19/19 at 11:42 a.m., S10RN confirmed she did not perform hand hygiene after she removed the right glove and before she donned another glove.

2) Failing to maintain a sanitary physical environment:

Breaches in food sanitation and temperature for sanitizing dishes:
On 3/19/19 at 12:30 p.m. an observation was made of a package of frozen hamburger patties thawing in the sink. The package was not completely submerged in water, and there was no water continuously running over the package. S13DM confirmed the findings during observation.

According to LAC, Title 51, Public Health - Sanitary Code, Part XXIII, Section 1315. Thawing, A.Potentially hazardous food shall be thawed by one of the following methods: 1. Under refrigeration that maintains the food temperature at 41 degrees F ( 5 degrees C) or below. 2. Completely submerged under potable running water at a temperature of 70 degrees F. ( 21 degrees C) or below with sufficient velocity to agitate and float off loose particles in an overflow, and for a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41 degrees (5 degrees C) for more than 4 hours including a. the time the food is exposed to the running water and the time needed; b. for preparation for cooking; or c. the time it takes under refrigeration to lower food temperature to 41 degrees F. (5 degrees C); 3. as part of the conventional cooking process; 4. Thawed in a microwave oven and immediately transferred to conventional cooking equipment and cooked as specified in Section 1305, with no interruption of the process.

According to LAC, Title 51, Public Health - Sanitary Code, Part XXIII, Section 2513. Sanitization: A. After food contact surfaces of all equipment and utensils are washed and rinsed, they shall be sanitized before use. Clean food contact surfaces of all equipment and utensils shall be sanitized in: 2. chemicals. iii. a quaternary ammonium compound solution shall: (a) have a minimum temperature of 75 degrees F, (b) have a concentration of 200mg/L (ppm) or as indicated by the manufacturers use directions included in labeling.

Review of the logs for the 3 compartment sink revealed the hypochlorite levels were documented as 50 ppm with no documentation of water temperatures.

S13DM confirmed, during review of the logs with the surveyor on 3/19/19 at 12:40 p.m., she had not been documenting the water temperatures for the 3 compartment sink. She confirmed she had only documented the chemical levels.

Breaches in cleaning and disinfecting environmental surfaces:
Observation on 03/19/19 at 8:40 a.m. revealed S11RN entered Room "c" to draw a blood sample. She placed the plastic bag containing lab tubes on the overbed table. After completing the blood draw S11RN placed the plastic bag that had been placed on the patient's overbed table on the table in the hall (used by staff as work space and containing a container of CaviWipes) outside the room. She then picked up the plastic bag of lab tubes and walked to the nursing station without cleaning the contaminated table in the hall outside Room "c".

Observation on 03/19/19 at 11:32 a.m. revealed S10RN entered Room "d" and placed the Accucheck supply tray on Patient #2's bedside table. She washed her hands and donned gloves. She placed the glucose test strip container on the overbed table (now contaminated). After completion of the CBG sample was obtained and resulted, S10RN picked up the contaminated container of strips with contaminated gloved hands and carried the container and the Accucheck tray out the room. She removed her right glove and walked to the medication cart where she placed the contaminated strip container and the contaminated Accucheck tray. She redonned a right glove without performing hand hygiene. After removing both gloves and performing hand hygiene, S10RN donned gloves and cleaned the glucometer with a SaniWipe and placed it in the tray. Continuous observation revealed S10RN didn't clean the contaminated container of strips before placing them in the tray, didn't disinfect the inside of the tray where she had placed the contaminated case after removing it from the patient's overbed table, and didn't disinfect the tray or the medication cart counter where the contaminated tray had been placed. Further observation revealed S10RN did not clean the glucometer in accordance with hospital policy.

Review of the policy titled "Device Cleaning - Incidentals", presented as a current policy by S1Adm, revealed all small devices such as glucometers and supplies/tools such as scissors must be disinfected with a hospital approved disinfectant (wipes - purple or gold top) between each patient use. The device must be visibly wet with disinfectant for 2 minutes to be effective. Clean device first with disinfectant wipe and then disinfect with a new wipe.

No policy and procedure was presented during the survey related to infection control other than a policy for disinfecting medical devices and supplies. Requests were made for infection control policies during the entrance conference on 03/18/19 at 8 :45 a.m. with S2DON and on 03/19/19 at 3:55 p.m. with S1Adm.

In an interview on 03/19/19 at 8:58 a.m., S11RN confirmed she didn't disinfect the contaminated surfaces.

In an interview on 03/19/19 at 11:42 a.m., S10RN confirmed she didn't disinfect the contaminated container of CBG strips, the Accucheck tray, and the surface of the medication cart.

Environmental Tour observations:
Observation during an environmental tour conducted on 03/18/19 at 8:50 a.m. revealed the following unsanitary conditions:
Room 120 with a hole approx. 3" to 4" in the sheetrock above the sink at the light fixture; ceiling tiles were removed;
Accumulation of water pooled on the floor in the public hall near Room 120;
Room 119 had dead bugs inside the light fixture; the ceiling tile was stained and buckled; the light fixture had a brown stain and dead bugs in the covering; a live wasp was on the ceiling tile; the toilet in the bathroom had green-tinged water and brown specks floating; a mouse trap was on the floor behind the closet;
Room 120 had a mattress (no bed present in the room) lying on floor against the table with dried brown particles on the bottom of the mattress with stains on the bed linens;
Room 116 with the toilet in the bathroom without water in the bowl with a brownish-yellow stain and dark brown residue; 7 ceiling tiles in the room had stains, 3 that had dark blackish spots;
Room 114 had 3 stained ceiling tiles; no water in the toilet in bathroom;
Light fixture in the hall between Rooms 111 and 113 had dead bugs in the covering; 2 ceiling tiles were stained; and
Room 112 had a toilet with a yellowish stain, and 1 ceiling tile was stained.
Rooms 112, 114, 116, 119, and 120 did not have patients admitted to the room.

Observation during an environmental tour conducted on 03/18/19 at 10:50 a.m. revealed the following unsanitary conditions:
Room 101 was used as storage and had a missing ceiling tile with tile particles scattered on the floor;
East hall outside the room designated as pharmacy (not being used as pharmacy) had a large ceiling tile removed with the ductwork and insulation exposed; another large ceiling tile was removed that had black plastic exposed from the ceiling; there were approximately another 5 ceiling tiles that were removed or partially removed with stains present and one tile with crumbled areas;
Rooms 143 and 144 had water running in the sink in the patient room with a sign on each that included "Hospital A Do Not Turn Off Hot Water."

Rooms 101, 143, and 144 did not have patients admitted to the room.

Observation on 03/20/19 at 4:00 p.m. revealed a wasp on the ceiling in Room 119 (no patient admitted to the room) and a wasp on the floor in the hall outside Room 117.

Review of the tool titled "Infection Control - Rounds", presented by S1Adm, revealed the tool had sections labeled as patient unit, personal protective equipment usage/hand hygiene practices, isolation, environment of care, other findings, and corrective actions. Further review revealed the tool was void of any documentation.

In an interview on 03/20/19 at 8:30 a.m. when the environmental tour findings were reviewed with S2DON, she offered no explanation for the findings.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the infection control rounds had not been conducted and documented.

In an interview on 03/20/19 at 4:30 p.m., S1Adm indicated the hospital had a pest control contract but did not present such a contract during the survey. She acknowledged the hospital had a problem with wasps inside the building.

3) Failing track, measure, analyze, and trend infections as evidenced by having the tracking report and log void of documentation:

Review of the tools titled "St. Theresa Specialty Hospital Infection Control Tracking Report 2019" and "Infection Control Log", presented by S1Adm, revealed no documented evidence of documentation on either form.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed that she and S2DON had been the infection control officers and neither of them were qualified to be the officer. She confirmed that infections were not being logged, measured, analyzed, tracked, and trended.

4a) Failing to implement hospital staff-related measures as evidenced by (a) failure to have current TB test results in accordance with the OPH guidelines:

Review of the Louisiana Administrative Code, "Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by the Louisiana Department of Health shall be free of tuberculosis in a communicable state as evidenced by either: 1) a negative PPD skin test given by the Mantoux method or a blood assay for Mycobacterium tuberculosis; 2) a normal chest x-ray if the skin test or blood assay is positive; or 3) a statement from a licensed physician certifying the individual is non-infectious if the x-ray is other than normal. In order to remain employed, the individual shall be rescreened annually by one of the following methods: purified protein derivative skin test for TB given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration remains negative, or a completed questionnaire asking of the person pertinent questions related to active TB symptoms, including, but not limited to: do you have productive cough that has lasted at least 3 weeks, are you coughing up blood, have you had an unexplained weight loss recently, have you had fever, chills, or night sweats for 3 or more days. Any employee converting from a negative to a positive skin test for TB or a blood assay or having indicated symptoms of active TB revealed by the completed questionnaire shall be referred to a physician and followed as indicated.

Review of the personnel files of S2DON, S10RN, and S18RT revealed no documented evidence of current TB test results.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the above-listed personnel files did not have a current TB test result.

4b) Failure to have documented evidence of new employee and regular update training in preventing and controlling HAI and methods to prevent exposure to and transmission of infections and communicable diseases:
Review of the personnel files of S1Adm, S2DON, S9RN, S10RN, S11RN, S12HK, S13DM, S17Diet, and S18RT revealed no documented evidence of training upon hire and updated training in infection control.

No policy and procedure was presented during the survey related to infection control other than a policy for disinfecting medical devices and supplies. Requests were made for infection control policies during the entrance conference on 03/18/19 at 8:45 a.m. with S2DON and on 03/19/19 at 3:55 p.m. with S1Adm.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed infection control training had not been conducted for the above-listed staff.

5) Failing to perform active surveillance to monitor compliance with hand hygiene practices by staff:

Review of the "Hand Hygiene/Glove Use Observation" tool presented by S1Adm revealed the tool was void of observations made.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed hand hygiene surveillance had not been performed.

6) Failing to ensure expired medical supplies had been removed from inventory enabling expired medical supplies to be available for use.

Observations during the environmental tour conducted on 03/18/19 at 8:50 a.m. revealed the following expired supplies that remained in inventory and was available for use:
Room 117 - unlocked supply room with the following expired items:
Curity Iodoform Packing Strip expired 04/17;
1 box containing 9 Hollister Urinary Pouches expired 10/18;
3 oz. Antifungal Powder with Miconazole Nitrate 2% expired 10/18;
1 box (50 packets) Povidone-Iodine Swabsticks expired 11/18;
1 full box (50 packets) and 1 opened box Compound Tincture of Benzoin Swabsticks expired 01/19.

In an interview on 03/20/19 at 8:30 a.m. when the environmental tour findings were reviewed with S2DON, she indicated the staff member responsible for the supply inventory was out ill. She further indicated they don't use most of the supplies kept in the supply room. S2DON offered no further explanation for having expired inventory available for use.










30984

Based on record review and interview, the hospital failed to have written policies and procedures in place to address the hospital's organ, tissue, and eye procurement responsibilities.

Findings:

A list of the hospital's policies, including policies related to organ procurement, was requested on survey team entry on 3/18/19.

Review of the hospital's policies/qwritten protocols provided for survey team review revealed no documented evidence that the hopsital had written protocols/procedures/policies to address it's organ procurement responsibilities.

On 03/21/19 at 1:20 p.m. a final request was made to S1Adm for protocols/procedures/policies regarding the hospital's organ procurement responsibilities. S1Adm failed to produce any documents as of survey team exit on 3/21/19.

Based on policy review and interview, the hospital failed to ensure written protocols were established for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital. This deficient practice was evidenced by failure of the hospital to establish written protocols for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital.

Findings:

Review of the hospital's policies and procedures revealed no documented evidence of written protocols/policies for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital.

In an interview on 03/21/19 at 1:20 p.m. with S1Adm failed to produce any policies/protocols for the timely notification of the OPO of individuals whose death is imminent or who have died in the hospital.

Based on record review and interview, the hospital failed to have an agreement with at least one eye bank and tissue bank to cooperate in the retrieval, processing, preserving, storage and distribution of eyes of potential donors.

Findings:

Review of the hospital's contracts revealed no documented evidence of a contractual agreement with a tissue or an eye bank.

In an interview on 03/21/19 at 1:20 p.m. with S1Adm, she verified there she could not locate an eye bank contract.

Based on record review and interview, the hospital failed to designate a director of rehabilitation services who had the knowledge, experience, and capabilities to properly supervise and administer the services as evidenced by having no individual designated as the director of rehabilitation services.
Findings:

Review of the minutes for the Governing Body revealed no documentation that anyone was appointed Director of Rehabilitation Services.

On 03/19/19 at 2:40 p.m. in an interview with S8PT, she confirmed she had not been appointed by the hospital to serve as the Director of Rehabilitation Services. S8PT stated there is currently no Director of Rehabilitation Services.

Based on record reviews and interview, the hospital failed to ensure rehab services were provided in accordance with orders as evidenced by failure to have OT services provided for 1 (#4) 2 patients (#4, #9) with orders for OT and failure to notify the physician when PT services were discontinued due to patient noncompliance for 1 (#3) of 3 (#3, #4, #9) patient records reviewed with PT orders from a sample of 30 records.
Findings:

Patient #3
Review of Patient #3's medical record revealed a PT evaluation was performed on 02/13/19 with a plan established for PT 4 times a week for 4 weeks.

Review of the PT progress notes revealed an entry on 02/26/19 that PT skilled services were discontinued due to Patient #3's refusal to participate. There was no documented evidence S3MedDir was notified that PT services were discontinued.

Patient #4
Review of Patient #4's medical record revealed an admission order on 02/13/19 at 1:00 p.m. for a PT, OT, and ST evaluation.

Review of Patient #4's medical record revealed no documented evidence that Patient #4 received an OT evaluation as ordered.

In an interview on 03/19/19 at 2:37 p.m., S2DON indicated she sent Patient #3's chart and PT notes to Patient #3's orthopedist (who was not privileged at the hospital) notifying him that Patient #3 was refusing therapy. She said she didn't notify S3MedDir but told the NP that PT was being discontinued. She further indicated she didn't document the notification of the NP. S2DON confirmed an OT evaluation and follow-up OT treatment was not done for Patient #4.

Based on interview, the hospital failed to ensure a physician with the knowledge, experience, and capabilities was privileged as director of respiratory care services to supervise and administer the service properly as evidenced by failure to have appointed and privileged a physician as director of respiratory services.
Findings:

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed a qualified physician had not been appointed and privileged to serve as the director of respiratory services.

Based on record reviews and interview, the hospital failed to ensure respiratory services were administered in accordance with medical staff directives and hospital policy as evidenced by failure to have documented evidence of a respiratory assessment conducted by a respiratory therapist prior to initiation of respiratory treatment in accordance with hospital policy for 3 (#4, #7, #8) of 9 (#1 - #9) patient records reviewed with respiratory treatments ordered from a sample of 30 patients.
Findings:

Review of the policy titled "Assessment/Reassessment Of patients", presented as a current policy by S1Adm, revealed all patients receive a respiratory screen upon admission and a respiratory consult is requested if necessary. Patients admitted with pulmonary processes the require mechanical ventilation will be assessed at the time of admission. Those requiring less extensive respiratory therapy, such as oxygen per mask or nasal cannula, will be assessed within 8 hours of admission.

Patient #4
Review of Patient #4's medical record revealed he was admitted on 02/13/19 and had admit physician orders for oxygen at 3 liters per minute via nasal cannula. Review of his entire medical record revealed no documented evidence that he had been assessed by the respiratory therapist as of the date of the record review on 03/19/19.

Patient #7
Review of Patient #7's medical record revealed he was admitted on 11/18/18 and had orders written on 11/21/18 for Advair 50/500 mg 1 puff BID. Review of heis entire medical record revealed no documented evidence that he had been assessed by the respiratory therapist as of the date of the record review on 03/19/19.

Patient #8
Review of Patient #8's medical record revealed she was admitted on 11/18/18 and had an order written on 11/26/18 for oxygen at 2 liters per nasal cannula now. Review of her entire medical record revealed no documented evidence that she had been assessed by the respiratory therapist as of the date of the record review on 03/19/19.

In an interview on 03/20/19 at 8:30 a.m., S2DON reviewed Patient #4's medical record and confirmed there was no documented evidence that an assessment had been conducted by the respiratory therapist.


39791

Based on record reviews and interview, the hospital failed to ensure respiratory services procedures were performed by qualified personnel as evidenced by failure to have documented evidence of current licensure, orientation, and competency evaluation of 1 (S18RT) of 1 respiratory therapist employed and failure to have documented evidence of training and competency evaluation in performing respiratory services for 4 (S2DON, S9RN, S10RN, S11RN) of 4 RN personnel files reviewed for training and competency to perform respiratory therapy services.
Findings:

No personnel file was available for review for S18RT. There was no documented evidence presented of current licensure, orientation, training, and an evaluation of competency.

Review of the personnel files of S2DON, S9RN, S10RN, and S11RN revealed no documented evidence of training in and evaluation of competency in performing respiratory therapy services.

In an interview on 03/20/18 at 1:20 p.m., S1Adm confirmed that the RNs perform respiratory therapy services when the respiratory therapist was not onsite. She confirmed there was no documented evidence of training in and evaluation of competency in performing respiratory therapy services for the above-listed RNs.

In an interview on 03/20/19 at 2:10 p.m., S1Adm confirmed she did not have a personnel file for S18RT and thus did not have documentation of current licensure, orientation, training, and a competency evaluation.

Based on record review and interview, the hospital failed to ensure its EP plan was reviewed and updated at least annually as evidenced by not having the plan reviewed and updated since 06/11/13.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the manual and plan had not been reviewed and updated since 06/11/13.

Based on record review and interview, the hospital failed to ensure its EP plan was based on and included a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach as evidenced by failure to have a documented assessment for review.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that a facility-based and community-based risk assessment, utilizing an all-hazards approach, had been conducted.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the manual and plan had not been reviewed and updated since 06/11/13, and an assessment as stated above had not been done.

Based on record review and interview, the hospital failed to ensure its EP plan included policies and procedures for safe evacuation from the hospital that included consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation locations, and primary and alternate means of communication with external sources of assistance as evidenced by failure to have an updated EP that included these requirements.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that policies and procedures were developed for safe evacuation that included consideration of care and treatment needs of evacuees, staff responsibilities, transportation, identification of evacuation locations, and primary and alternate means of communication with external sources of assistance.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed policies and procedures had not been developed that addressed the requirements for safe evacuation from the hospital.

Based on record review and interview, the hospital failed to ensure its EP plan included policies and procedures for a means to shelter in place for patients, staff, and volunteers who remain in the hospital as evidenced by the EP not including sheltering in place procedures.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that policies and procedures were developed for sheltering in place.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed policies and procedures had not been developed that addressed sheltering in place.

Based on record review and interview, the hospital failed to ensure its EP plan included policies and procedures related to a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records as evidenced by failure of the EP to address the specific procedures for medical documentation to assure preservation of information, confidentiality of patient information, and the availability of records.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that policies and procedures were developed related to medical documentation.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed policies and procedures had not been developed that addressed the specific procedures for medical documentation during a disaster.

Based on record review and interview, the hospital failed to ensure its EP plan included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers, if applicable.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that a communication plan had been developed that included the names and contact information for staff, entities providing services under arrangement, patients' physicians, other facilities, and volunteers, if applicable.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the above-listed required names and contact information was not included and/or updated in the EP plan.

Based on record review and interview, the hospital failed to ensure its EP plan included the contact information for federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance as evidenced by failure to have such documented contact information.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that the plan included the contact information for federal, state, tribal, regional, and local emergency preparedness staff and other sources of assistance.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the above-listed required contact information was not included and/or updated in the EP plan.

Based on record review and interview, the hospital failed to ensure its EP plan included a method for sharing information and medical documentation for patients under its care with other health providers to maintain the continuity of care, the means, in the event of an evacuation, to release patient information, and the means of providing information about the general condition and location of patients under the hospital's care as evidenced by failure to have policies and procedures developed that address these topics.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that the plan included a method for sharing information and medical documentation for patients under its care with other health providers to maintain the continuity of care, the means, in the event of an evacuation, to release patient information, and the means of providing information about the general condition and location of patients under the hospital's care.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the above-listed required information was not included in the hospital's EP plan.

Based on record review and interview, the hospital failed to ensure its EP plan included a means of providing information about the hospital's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or its designee as evidenced by failure to address how information regarding occupancy, needs, and the ability to provide assistance would be communicated to the authority having jurisdiction.
Findings:

Review of the "Safety/EOC Policy and Procedure Manual", presented as the hospital's current EP plan by S1Adm, revealed the plan and manual had not been reviewed since 06/11/13. Further review revealed no documented evidence that the plan included the means of providing information about the hospital's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center, or its designee.

In an interview on 03/20/19 at 1:20 p.m., S1Adm indicated the EP plan had not been revised in accordance with the new federal EP regulations. She confirmed the plan had not been developed related to communication of the hospital's occupancy, needs, and ability to provide assistance.

Based on record review and interview, the hospital failed to ensure its EP training program included training in EP policies and procedures to all new and existing staff and individuals providing services under arrangement upon hire and at least annually, maintained documentation of the training, and included demonstration of staff knowledge of emergency procedures. This deficient practice was evidenced by failure to have documented evidence that EP training had been conducted upon hire and at least annually with documentation of the demonstration of staff knowledge of emergency procedures for 12 (S1Adm, S2DON, S3MedDir, S4NP, S7NP, S9RN, S10RN, S11RN, S12HK, S13DM, S17Diet, S18RT) of 12 personnel/credentialing files reviewed for EP training.
Findings:

Review of the personnel/credentialing files of S1Adm, S2DON, S3MedDir, S7NP, S9RN, S10RN, S11RN, S12HK, S13DM, and S17Diet revealed no documented evidence that each had received EP training upon hire and at least annually thereafter and had been evaluated for knowledge of emergency procedures There were no personnel/credentialing files presented for S4NP and S18RT.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed the above-listed staff had not received EP training and had not been evaluated for knowledge of emergency procedures.

Based on interview, the hospital failed to ensure exercises to test the EP plan was conducted at least annually by having a full-scale exercise that was community-based or facility-based and an additional exercise that included a second full-scale exercise or a tabletop exercise as evidenced by failure to have documented evidence that two such exercises had been conducted annually.
Findings:

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed she had no documentation of EP drills to present for review.

Based on record reviews and interview, the administrator, medical staff, and DON failed to ensure the hospital-wide QAPI program addressed problems identified by the infection control officer(s) and was responsible for the implementation of successful corrective action plans in the affected problem areas as evidenced by failure to have infection control data collected, measured, analyzed, and trended with results addressed in the QAPI program and corrective action developed to address problem areas.
Findings:

No infection control data collection was presented for review during the survey by S1ADM or S2DON.

Review of the document titled "Hospital QI Reporting", presented by S1Adm, revealed the quarterly infection control quality and performance improvement report would be reported to the Medical Executive Committee and then to the Board quarterly.

In an interview on 03/20/19 at 1:20 p.m., S1Adm confirmed no infection control data had been collected, measured, analyzed, and trended and no active surveillance had been conducted related to hand hygiene and environmental rounds. She confirmed, therefore, no infection control data had been submitted for review to the Medical Executive Committee and Board as required by the document noted in the above paragraph.