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Based on observations and interview, the hospital staff failed to ensure its staff was trained for non - medical emergencies such as fire training for 4 of 5 hospital staff members. (Director of Respiratory, Respiratory therapist, Radiology Technician 1 and 2)


The findings are:

On 09/14/15 at 1:40 p.m., during an interview with the Respiratory Director, the respiratory Director revealed limited knowledge on fire training protocol and only verbalized the acronym "race".

On 09/14/15 at 1:41 p.m., during an interview with the Respiratory Therapist, the Respiratory Therapist revealed limited knowledge on fire training protocol and only verbalized the acronym "race".

On 09/15/15 at 2:30 p.m., during an interview with Radiology Technician 1, Radiology Technician 1 revealed limited knowledge on fire training protocol and only verbalized the acronym "race" used for fire.

On 09/15/15 at 2:32 p.m., during an interview with Radiology Technician 2, Radiology Technician 2 revealed limited knowledge on fire training protocol and only verbalized the acronym "race".

Based on observations, interviews, review of personnel files, review of job descriptions, and review of the hospital's policies and procedures, hospital management failed to ensure that its dietary services department had qualified staff with supervision and monitoring to assure competency in providing dietary services for patients, and the hospital failed to minimize the potential transmission of infectious agents for 2 of 2 Certified Nursing Assistants (CNA), 1 of 1 Clerk, 1 of 1 Respiratory Directors, 2 of 3 Registered Nurses (RN), 1 of 1 dietary supervisors, and failure to ensure a facility wide system for monitoring infections by 1 of 1 Infection Control Officer. (CNA 2 and 3, Clerk, Respiratory Director, RN 2 and 3, and Infection Control Officer, Dietary Supervisor)


The findings are:

On 09/14/2015 at 12:05 p.m. through 12:45 p.m., observations in the hospital's kitchen with the Dietary Supervisor revealed the supervisor wore the same pair of blue gloves without performing hand hygiene throughout the tour.

On 09/14/2015 at 12:05 p.m., observations of the manual dish washing procedures in the 3 compartment sink revealed the Dietary Supervisor removed a strip from the bottle located above the sink and swished the strip for a in the sink filled with the water and the disinfectant. When asked how long strip was to be swished, the Dietary Supervisor stated, "thirty seconds". When asked to review the information on the bottle that contained the strips(QAC QR Test Strips Code 2951), the Dietary Supervisor reported that the directions stated the strip was to be swished for 5 seconds in the water solution. Then, the Dietary Supervisor was observed to swish another strip in the water with the disinfectant. When asked how long the strip had been swished, the Dietary Supervisor who wore no watch and did not look at the clock on the opposite wall to time the strip, retrieved another strip from the bottle, and for the third time, swished the strip in the sink of water with the disinfectant, counted to five, removed the strip and placed the strip next to the pictures on the bottle label and stated the strip looked like either picture 3 or 4. The color of the water with the disinfectant in the sink was a dark blue during the observation. Observation of the label on the 2 bottles of strips revealed the 2 bottle of strips expired March 2015. Review of the bottle of tablets(Steramine 1g) used for disinfectant for the water in the 3 compartment sink revealed to use 20 tablets for each 20 gallons of water. Observations revealed the sink was not marked at the 20 gallon level. The Dietary Supervisor reported that he/she was told that you just fill the sink with water to the rim. The Dietary Supervisor used all of the expired strips from the bottle on 09/14/2015 at 12::05 p.m., and stated that he/she would have to order more strips and the strips would not be in until next week. From 09/14/15 to 09/18/15, the Dietary Supervisor had no strips to measure the effectiveness of the disinfectant in the water of the 3 compartment sink.

On 09/14/2015 at 12:15 p.m., observations of the tray preparation line showed the prepared foods for the lunch meal consisted of spaghetti noodles, spaghetti sauce, and mixed vegetables. Observations showed the Dietary Supervisor went to the tray preparation line without performing hand hygiene and wore the same blue gloves when plating the food. The Dietary used no utensils to assure accurate proportions in plating the foods. When the Dietary Supervisor was asked if all patients receive the same menu items, the Dietary Supervisor stated, "yes". When asked if a patient was on a low salt low fat 2 gram diet or a diabetic diet, what the patient would receive on their tray, the Dietary Supervisor reported that he/she would remove the salt and pepper packets from those patient trays.

On 9/15/15 at 9 a.m., observations of the Dietary Supervisor using the dishwasher revealed the Dietary Supervisor did not know if the dishwasher was a low temperature or high temperature dishwasher although a sign was posted on the wall that it was a low temperature dishwasher. Observations showed the Dietary Supervisor removed food refuse from the breakfast dishes and sprayed the soiled dishes over the sink with the water sprayer. The dishwasher stopped, the Dietary Supervisor pulled up the covering of the dishwasher, and wearing the same blue gloves worn to remove debris from the dirty dishes, rearranged all the dishes in the dishwasher after stating the dishes were not clean. Then, the Dietary Supervisor went back to scraping the and spraying the other dirty dishes. Observation of the dishes in the dishwashing machine revealed food debris on the dishes that had cycled through the dishwasher. The dishes in the dishwasher required three complete cycles to get the dishes clean and Dietary Supervisor moved between the dirty area and the dishwasher without hand hygiene or changing gloves. On 9/15/15 at 9:30 a.m., during an interview with the Dietary Supervisor, the Dietary Supervisor reported that the dishwasher had no been functioning well and frequently required several cycles to get each load of dirty dishes clean. The Dietary Supervisor stated that someone had performed maintenance on the dishwasher several weeks ago and the maintenance form was on the bulletin board on the wall. Review of the forms on the bulletin board showed maintenance dated 2014. No other maintenance forms were presented. On 9/15/15 at 09:30 a.m., the Dietary Supervisor verified that she had not changed gloves or performed hand hygiene when moving from a the dirty area to the clean area. On 09/15/15 at 09:30 a.m., the Dietary Supervisor reported that she did not perform the cleaning as listed on the signs by the dishwasher that should be done daily such as removing the swing arm and rinsing thoroughly. The Dietary Supervisor stated that she just sprays the machine at the end of the day.

Observation on 09/17/2015 at 09:15 a.m., that water in the 3 compartment sink was a pale blue. The Dietary Supervisor reported that the 3 compartment sink leaks and he/she has to keep adding water to the sink. The Dietary Supervisor stated that she had no work order to repair the sink leak.




31395

On 09/14/15 at 12:40 p.m., random observations in the trauma room revealed opened tubing connected to a transport vent. On 09/14/15 at 12:42 p.m., the Director of Respiratory revealed, "when we use the vent on a patient, the vent is cleaned and the tubing is thrown away. We replace clean tubing on the vent. We only change the tubing when we use it on a patient. The last time the vent was used was probably last week or longer. I'm not exactly sure on the date".

On 09/14/15 at 1:10 p.m., observations in Emergency Room (ER) 3 revealed the CNA 1 walked into the room, donned gloves, removed paper lining from the stretcher, obtained a disinfectant wipe, cleaned the stretcher and side rails, removed gloves, and exited the room. CNA 1 failed to perform hand hygiene, clean the vital sign equipment, and clean the bedside chair. The findings were verified by RN 2.

On 09/14/15 at 1:20 p.m., observations of a triage patient revealed the CNA 2 called the patient into the triage room, placed the blood pressure cuff and pulse ox on the patient, used the forehead thermometer, obtained the patient's vitals signs, and then, removed the blood pressure cuff and pulse ox from the patient. CNA 2 escorted the patient to the assigned room, returned to the triage area, and sprayed disinfectant spray on the chair. CNA 2 failed to wipe down the surface of the chair, the blood pressure cuff, or the pulse ox equipment. On 09/14/15 at 1:30 p.m., CNA 2 revealed, "The nurses had already wiped down the blood pressure and pulse ox in the rooms if they used them. Normally, I just take the patient back to the room. I was just doing the nurse a favor when I wiped the bed down. They usually wipe everything down before I bring a patient back. I try to wipe it down (blood pressure cuff, pulse ox, chair) when my patient comes in the triage room so that they can see that it's clean". On 09/14/15 at 1:33 p.m., RN 2 revealed, "the nurse or technician is responsible for cleaning the patient rooms. It just depends on who has time to clean it."

On 09/15/15 at 10:23 a.m., review of the hospital's infection control program showed there was no evidence that the hospital selected nationally recognized infection controls guidelines and utilized those guidelines in the facility or had evidence that the infection control department monitored all hospital departments that includes but is not limited to: dietary, maintenance, housekeeping, radiology, lab, and the emergency department.

On 09/16/15 between 9:10 a.m. and 9:55 a.m., observations of RN 1 during medication administration with the assistance of the computer on wheels that was transported into 3 different patient rooms. Observations showed RN 1 failed to disinfect the computer on wheels between patient rooms.

Facility Policy and Procedure ,titled, "Infection Control Measures in the Emergency Department", reads, "....All equipment must be checked for cleanliness daily and prior to use...".

Facility Policy and Procedure, titled, "Infection Prevention Plan", reads, "...The Infection Prevention Nurse is responsible for the surveillance of the Infection Prevention Program...Routine collection of information about infection control issues through the following means...Provide ongoing review and evaluation of all aseptic, isolation, sterilization, and sanitation techniques in the hospital to minimize occurrences...".

Facility Policy and Procedure, titled, "Infection Prevention Program", reads, "....the daily activities of the Infection Control Program shall be the responsibility of the Infection Prevention Nurse...".

Facility Policy and Procedure, titled, "Handwashing and Hand Antisepsis", reads, "...C3. After removing gloves...".

Facility Policy and Procedure, titled, "Cleaning of Medical Equipment", reads, "...2e. non-disposable pulse oximetry probes should be cleaned Caviwipes after each use...2i. Non-disposable cardiac monitor should be cleaned with Caviwipes after each use...".






36295

On 09/16/15 at 11:20 a.m., observations of Certified Nursing Assistant(CNA) 3 using the glucometer in a patient room revealed CNA 3 did not clean and/or disinfect the glucometer case or meter after exiting the patient's room.


36397

On 9/14/15 at 12:05 p.m.., observations in the hospital's kitchen revealed a stacked tea bin without a cover that was placed with other clean items, top of dish storage cabinet was covered in layers of dust, observation of an oven with bread warming inside revealed the warming oven had a black substance coating the doors and inside the oven cavity, and both handles on warming oven were sticky to touch. During the tour, the Dietary Supervisor reported that one of the ovens, the steamer, the fryer, and other equipment was broken. The Dietary Supervisor did not have any maintenance orders for the broken equipment. On 9/14/15 at 12:05 p.m.., during an interview with the Dietary Supervisor , the Dietary Supervisor reported there was no routine cleaning schedule or maintenance for the equipment in the kitchen area.

On 9/14/15 at 12:10 p.m., observation of the dry storage revealed almond exact with a label opened 10/3/12 and a bottle of cinnamon labeled opened 1-10-12 on a shelf. Observations in the walk in refrigerator revealed a cantaloupe half dated 9/10/15 and a plate of mashed potatoes dated 9/12/15. Observation of a labeled bin holding flour revealed the scoop was located inside each bin.

On 9/15/2015 at 9:00 a.m., observations in the walk in refrigeration revealed there were no labels on the bins in walk-in refrigerator. Broccoli was in one bin without a label for the date placed there, and there were no labels on opened bottles of green food coloring and pure vanilla exact. On 9/15/15 at 9:00 a.m., the Dietary Supervisor verified the findings.

On 9/15/15 at 11:32 a.m., observations of the patient refrigerator located on the medical surgical unit revealed two small dead files on shelves in the door, 2 sandwiches dated 9/13/15 and then scribbled over the 9/13/15 was 9/14/15. The findings were verified by the housekeeper on 9/15/15 at 11:32 a.m.

On 9/15/15 at 2:50 p.m.., during an interview with the Maintenance Manager, the Maintenance Manager revealed there was limited communication record of repair problems of equipment in the kitchen and there were no updated maintenance records provided. The last noted maintenance report located on the bulleting board on the wall in the dishwashing room was dated 5/2014.

Based on record review and interview, the hospital failed to perform an annual review and/or revision of its health care policies and procedures for nursing, dietary, swing bed program, and administrative policies since 2012.
The findings are:
On 09/16/2015 at 1:20 p.m., a review of the hospital's administrative policy manual, dietary manual, swing bed program manual, and nursing manual revealed the policies and procedures reflected the date of last review and/or revision was 2012.
On 09/18/2015, at 12:00 p.m., review of the hospital's policy, titled, "Board Minutes as Policy," read, "Procedure 4.0- All policies will be reviewed every 2 years and revised as necessary."
On 09/17/ 2015 at 1:00 p.m., review of the hospital's annual program evaluation dated 2014 had documentation of an annual review of the hospital's policies and procedures as part of the hospital's annual program evaluation.
On 09/15/2015, at 4:00 p.m., during an interview with Quality Manager, the Quality Manager revealed that annual review of hospital policies and procedures is not a function of the quality team members.

Based on record review and interview, the hospital's Continuous Quality Improvement (CQI) team failed to use data obtained from identified quality indicators to develop a plan to assess, implement, track and monitor any findings, to evaluate its plan for effectiveness, and/ or take corrective actions based on the data.
The findings include:
On 09/18/2015 at 11:30 a.m., a review of the hospital's quality data and meeting minutes dated June 10, 2015 revealed the hospital's quality reporting indicators, but there was no evidence of targeted thresholds to determine action levels, no evidence that the identified target quality indicators were analyzed, no evidence that a plan was developed, implemented, tracked, monitored, evaluated for its effectiveness, or that any corrective actions were implemented based on the data.
One identified quality indicator for outpatient services was related to patients who failed to show for scheduled appointments. The data revealed that 9 percent of outpatients failed to show for scheduled appointments. On 09/18/2015 at 11:35 a.m., during an interview with the Quality Manager, the Quality Manager revealed the hospital calls any patients who fail to show for their scheduled appointments to determine what happened. The Quality Manager reported that the issue is discussed during the quality meetings, but the team had not identified a plan to increase compliance with scheduled appointments because "we can't come up with anything. We have no means of transportation to gather the patients and we cannot control the weather".
The hospital's quality management team identified that Automated Emergency Device (AED) checks were not completed in the Cardiac Rehabilitation/Physical Therapy (PT)/ Occupational Therapy (OT) location. On 09/18/2015 at 11:35 a.m., during an interview with the Quality Manager, the Quality Manager reported that meetings were held between the Cardiac Rehabilitation Department and Physical Therapy/Occupational Therapy related to the identified quality indicator but there was no documentation of the meetings and no documentation that a plan was developed and implemented to address the issue.

Based on record review and interview, the hospital evaluated but failed to take remedial actions to address deficiencies identified through its quality program.
The findings include:
On 09/18/2015 at 11:30 a.m., a review of the hospital's quality data and meeting minutes dated June 10, 2015 revealed the hospital's quality reporting indicators, but there was no evidence of targeted thresholds to determine action levels, no evidence that the identified target quality indicators were analyzed, no evidence that a plan was developed, implemented, tracked, monitored, evaluated for its effectiveness, or that any corrective actions were implemented based on the data.
One identified quality indicator for outpatient services was related to patients who failed to show for scheduled appointments. The data revealed that 9 percent of outpatients failed to show for scheduled appointments. On 09/18/2015 at 11:35 a.m., during an interview with the Quality Manager, the Quality Manager revealed the hospital calls any patients who fail to show for their scheduled appointments to determine what happened. The Quality Manager reported that the issue is discussed during the quality meetings, but the team had not identified a plan to increase compliance with scheduled appointments because "we can't come up with anything.
The hospital's quality management team identified that Automated Emergency Device (AED) checks were not completed in the Cardiac Rehabilitation/Physical Therapy (PT)/ Occupational Therapy (OT) location. On 09/18/2015 at 11:35 a.m., during an interview with the Quality Manager, the Quality Manager reported that meetings were held between the Cardiac Rehabilitation Department and Physical Therapy/Occupational Therapy related to the identified quality indicator but there was no documentation of the meetings and no documentation that a plan was developed and implemented to address the issue.

Based on record review and interview, the hospital's Continuous Quality Improvement (CQI) team failed to use data obtained from identified quality indicators to develop a plan to assess, implement, track and monitor any findings, to evaluate its plan for effectiveness, and/ or take corrective actions based on the data, and document any outcomes from implementation of its plan.
The findings are:
Cross Reference to W 0341: The hospital's Continuous Quality Improvement (CQI) team failed to use data obtained from identified quality indicators to develop a plan to assess, implement, track and monitor any findings, to evaluate its plan for effectiveness, and/ or take corrective actions based on the data.
Cross Reference to W 0342: The hospital failed to take remedial actions to address deficiencies identified through its quality program.

From 09/15/2015 through 09/17/2015, based on record review, interview, review of personnel job descriptions, review of 6 of 6 swing bed program patient charts, and review of the activities calendar, the hospital failed to provide evidence of an active program for activities for its swing bed population that lacked comprehensive assessments of swing bed patient's regarding their activity choices, lacked a qualified employee to supervise the program, lacked an interdisciplinary group of personnel for developing a plan of care and failed to include activities in the patient's plan of care.


The findings are:


On 09/15/2015 at 09:30 a.m., during an interview withe Director of Nurses, the Director of Nurses responded that she guessed that she was over the swing bed program. The Director of Nurses stated that she thought therapy was over the activity area.

On 9/16/2015 at 10:00 a.m., during a meeting with the Director of Nurses, the Occupational Therapist, and the Occupational Therapy Assistant, the Director of Nurses stated when asked the Occupational Therapist was the Activities Director. During the interview, the calendar submitted for activities was reviewed. The calendar listed one event each day but had no time with the date that the event was planned. The calendar listed one of these activities per day: DVDs, puzzles, knitting, books/magazines, crafts, etc. The Occupational Therapist verified that the activities calendar was not located in each patient's room so that the patient would know what and when an activity was planned. The Occupational Therapist also verified that the selection of the activities was not based on the patient's individualization.

On 09/15/2015 from 09/15 a.m. through 3:30 p.m., 6 of 6 patient charts for patients in the hospital's swing bed program revealed that none of the patient's had a documented comprehensive assessment for the activities program and none the patient charts had activities address on their care plans. Any documentation related to activities was one or two sentences that stated that a DVD was left in the patient room or a patient painted a flower. or the patient didn't feel like an activity.

On 09/17/2015 at 1:00 p.m., the Occupational Therapist reported that he/she was a contract employee who begin working at the hospital on 09/14/2015. He/She stated that the Occupational Therapy Assistant was also a contracted employee who had been at the hospital a little longer than he/she had. During the interview, the Occupational Therapist stated that until Tuesday, 9/15/2015, he/she was not aware that the activities program would be his/her responsibility. The Occupational Therapist verified that he/she had no experience as an Activity Program Director. The Occupational Therapist stated that he/she had a 14 week contract with the hospital.

Review of the Occupational Therapist and the Occupational Therapy Assistant's job description revealed there is no listing of the responsibility for the hospital's activities program for its swing bed program.

Based on review of the hospital's contracts for its telestroke agreement, telepsychiatry agreement, and hospital transfer agreement and staff interviews, the hospital failed to ensure that its contracts were renewed prior to the expiration date 3 of 7 contract agreements.

The findings are:

On 9/14/15 at 2:00 p.m., review of the hospital's telestroke agreement had no signatures and no effective date. On 9/14/15 at 2:30 p.m., review hospital's transfer agreement showed an expiration date of August 1, 2015.
On 9/14/15 at 2:30 p.m., review of the hospital's telepsychiatry agreement showed an expiration date of 2014. On 9/14/15 at 2:30 p.m., the Director of Nursing verified the finding. On 9/18/15 at 10:20 a.m., the Quality Manager verified the all three agreements had expired.

On 9/15/15 at 12:45 p.m., review of the hospital's Medical Staff Bylaws 2015, reads, "6.5.4 All telemedicine services will be evaluated for quality of services, timeliness, and appropriateness by the Medical Executive Committee on an annual basis."

On 9/15/15 at 1:00 p.m., review of 4 multiple telemedicine service data had no documentation of any feedback and/or communication to evaluate the services provided. On 9/15/15 at 2:45 p.m., the Quality Manager reported there was no documentation related to for communication on the data received from nor the data sent to the distant-site entities. The Quality Manager stated, "Just getting started and will incorporate it into our quality program".

Based on observations, review of patient records, interviews, review of personnel data, review of personnel job descriptions, review of hospital policies and procedures, and review of the hospital's infection control and quality data, the governing body failed to ensure that the Dietary Department operated in a responsible manner to ensure the safety of patients and/or staff.

The findings are:

Cross Reference to C 0241: The hospital failed to ensure that the Dietray Services Department operated in a responsible manner to ensure the safety of those patients.

Based on observations, interviews, and interviews, the hospital failed to ensure that the Dietary Services Department operated in a responsible manner to ensure the safety of those patients.

The findings are:

Cross Reference to C 0278: Hospital management failed to ensure that its dietary services department had qualified staff with supervision and monitoring to assure competency in providing dietary services for patients,

Cross Reference to C 0279: The hospital failed to ensure its supervisory dietary staff were knowledgeable in the provision of physician ordered therapeutic diets required to meet the nutritional needs of the patient, knowledgeable in developing menus that meet the therapeutic as well as substitution requirements for individualization of patient diets, and failed to ensure that the hospital provided qualified staff responsible for the supervision of its dietary services.

Based on observations, record reviews, interviews, review of personnel job descriptions, personnel files, review of the hospital's policies and procedures, the hospital failed to ensure hospital that its dietary services department had qualified staff with supervision and monitoring to assure competency in providing dietary services for patients, failed to show evidence that it completed an annual review of its patient care policies and procedures by the group professional personnel that includes the hospital's healthcare staff and one or more doctors of medicine, the Registered Nurse failed to provide comprehensive assessments and develop nursing care plans for patients admitted for inpatient services, Registered Nurses developed and implemented nursing care plans, updates care plans daily, and identify patient needs, and hospital staff failed to document the respiratory status and wound status on the patient's initial assessment of health status, and failed to ensure physician orders were obtained for wound care or for insertion of a Foley catheters.

The findings are:

Cross Reference to C 0272: The hospital failed to show evidence that it completed an annual review of its patient care policies and procedures by the group professional personnel that includes the hospital's healthcare staff and one or more doctors of medicine.
Cross Reference to C 0276: The hospital failed to properly label open medications and remove expired medications.

Cross Reference to C 0278: Hospital management failed to ensure that its dietary services department had qualified staff with supervision and monitoring to assure competency in providing dietary services for patients, and the hospital failed to minimize the potential transmission of infectious agents for 2 of 2 Certified Nursing Assistants (CNA), 1 of 1 Clerk, 1 of 1 Respiratory Directors, 2 of 3 Registered Nurses (RN), 1 of 1 dietary supervisors, and failure to ensure a facility wide system for monitoring infections by 1 of 1 Infection Control Officer. (CNA 2, and 3, Clerk, Respiratory Director, RN 2 and 3, and Infection Control Officer, Dietary Supervisor)

Cross Reference to C 0279: The hospital failed to ensure its supervisory dietary staff were knowledgeable in the provision of physician ordered therapeutic diets required to meet the nutritional needs of the patient, knowledgeable in developing menus that meet the therapeutic as well as substitution requirements for individualization of patient diets, and failed to ensure that the hospital provided qualified staff responsible for the supervision of its dietary services.

Cross Reference to C 0296: The Registered Nurse failed to provide comprehensive assessments and develop nursing care plans for patients admitted for inpatient services.

Cross Reference to C 0298: The hospital failed to ensure its Registered Nurses developed and implemented nursing care plans, updates care plans daily, and identify patient needs for 13 of 20 closed patient records.

Based on review of the hospital's policy and procedure manuals for its administrative policies, dietary policies, nursing policies, and swing bed policies, the hospital failed to show evidence that it completed an annual review of its patient care policies and procedures by the group professional personnel that includes the hospital's healthcare staff and one or more doctors of medicine.
The findings are:
On 09/14/2015 at 9:50 a.m., review of the hospital's written policy and procedure manuals revealed there was no evidence of an annual update by the group of professional personnel since 2012.
On 09/14/15 at 12:05 p.m., during an interview with Director of Nursing(DON), the DON verified that the hospital's policies and procedures had not been updated sine 2012.
Hospital policy, titled, "Policy Approval and Maintenance", reads, "....10.0 ." All Department Directors are responsible for reviewing their department policies at least annually making changes and documenting changes and documenting in the front of their manual that the review has been done".




36294

On 09/16/2015 at 1:20 p.m., a review of the hospital's administrative policy manual, dietary manual, swing bed program manual, and nursing manual revealed the policies and procedures reflected the date of last review and/or revision was 2012.
On 09/15/2015, at 4:00 p.m., during an interview with Quality Manager, the Quality Manager revealed that annual review of hospital policies and procedures is not a function of the quality team members.

Based on observations, interviews, and review of the hospital policy and procedures, the hospital failed to properly label open medications and remove expired medications.

The findings are:

On 09/14/15 at 2:50 p.m., random observations in the hospital's pharmacy revealed opened bottles of 16 fluid (fl) ounce (oz) of Ferrous Sulfated, 8 fl oz of Multi-Delyn Liquid, Rantidine syrup 15 milligrams (mg) per milliliter (ml) and 12 fl oz of Mylanta. Further observations revealed expired Potassium Chloride tablets x 2 dated 01/2015 and 12 expired vials of Infede 100 mg/ml dated 08/2015. The hospital failed to date, time, and initial the opened bottles and failed to remove outdated medications. The findings were verified with the Certified Pharmacy Technician. On 09/14/15 at 2:50 p.m., the Certified Pharmacy Technician revealed, "If we were required to date open items in the pharmacy, I wasn't aware."




36295

On 09/14/15 at 1:45 p.m., observations of the Medcil revealed Ipratropium Bromide expired on 08/15. On 09/14/15 at 2:00 p.m., Registered Nurse 4 revealed pharmacy checks for expired medications every week, but the medication had not been removed.

Based on observations, interviews, and record reviews, review of the hospital's patient menus, and review of the hospital's personnel files, the hospital failed to ensure its supervisory dietary staff were knowledgeable in the provision of physician ordered therapeutic diets required to meet the nutritional needs of the patient, knowledgeable in developing menus that meet the therapeutic as well as substitution requirements for individualization of patient diets, and failed to ensure that the hospital provided qualified staff responsible for the supervision of its dietary services.

The findings are:

On 9/14/15 at 12:15 p.m., observation of the food service line revealed the Dietary Supervisor preparing the lunches for 6 patients. Food items were spaghetti noodles, a red meat sauce, mixed vegetables, bread, and prepackaged jello. Observation revealed the Dietary supervisor wore the same blue gloves to prepare the patient food trays that he/she had worn throughout the tour of the dietary area. The Dietary Supervisor did not use utensils designed for food portioning as the different items were placed on each of the 6 patient plates. There were no other food items prepared for substitution items. When asked about food substitutions, the Dietary Supervisor reported that he/she would take a frozen chicken breast out of the freezer and prepare that for the patient and stated that it would take about 20 minutes to prepare the frozen chicken breast.

On 9/14/15 at 4:00 p.m., review of a book with various menus was brought for review of the menus. The menus in the book were dated 2014 and the food items that were served for the lunch meals were different from the items listed on the menu in the book for 9/14/2014 lunch menu. It was determined that the book of menus dated 2014 was no longer used. The Dietary Supervisor submitted the menu for the week.

The weekly menu showed that for each morning during the week of the survey the breakfast was listed as: eggs, sausage, bacon, grits, coffee, milk and juice. The Dietary Supervisor reported that each patient received that for their breakfast tray. When the Dietary Supervisor was asked if there were any menus for therapeutic diets or substitutions, the dietary supervisor reported that there were none. The Dietary Supervisor stated, "I just hold the salt and pepper on diabetics and patients that should not have salt".

On 9/15/15 at 10:35 a.m., during an interview with Registered Dietician(RD), the RD reported that she was aware of the issues in the dietary department but he/she had only just started 2 weeks ago. The RD stated that he/she was responsible for Cardiac Rehab patients, Home Health Care patients, and Diabetic education, but he/she was not directly responsible for the supervision of the kitchen.

On 9/15/15 at 12:20 p.m., observation of the patient food trays delivered to the medical surgical unit showed 5 of the 6 patient's received a breaded fish, spinach, bread roll, and milk. 1 of 6 patients received a breaded chicken breast, spinach, bread roll, and milk. The tray cards sent with each patient tray had the correct ordered diet for each tray although the diet served was a regular diet. Three of the 6 patients were ordered therapeutic diets but received regular diets.

Patient 1 was admitted on 09/03/15 with a physician diet for Diabetic. The patient received a regular diet on 09/15/2015 for the breakfast and lunch meals.

Patient 2 was admitted on 09/08/2015 with a physician diet order for Diabetic Diet. Patient 2 received a regular diet for the breakfast and lunch meal.

Patient 6 was admitted on 09/09/15 with a physician diet order for Low Sodium, 2 gram Na, Salt Restricted Diet. Patient 6 received a regular diet for the breakfast and lunch meal on 09/15/2015.

On 9/15/15 at 12:20 p.m.., Dietary Supervisor revealed he/she had no formal training for food services in a health care facility and stated, "No guidelines to follow".

On 9/15/15 at 1:00 p.m., review of the Dietary Supervisor's personnel chart revealed no documentation of required education, training, or experience as specified on the hospital's job description and no previous experience in a health care facility was identified on the Dietary Supervisor's employment application met the requirements. Review of the Food Service supervisor's job summary and specifications showed,"Education: Completion of Dietary Managers Course or 2 to 3 years experience in institutional service; Experience: 2 - 3 years experience in food preparation and supervision; Licensure, Registry or Certification Required: Dietary Manager's Certificate, Heart saver CPR.
Special Training: Must attend general hospital mandatory training, and additional department requirements on an annual basis. Must possess knowledge and skills necessary to serve patients of all ages including infants, pediatrics, adolescents, adults."

On 9/15/15 at 1:50 p.m., the Registered Dietitian submitted an alternate menu but reported that the items listed on the alternate menu were not available as of yet and he/she is still working on the list.

On 9/17/15 at 8:40 a.m., during an interview with new admission Patient 7 Patient 7 who was ordered a diabetic diet revealed the breakfast received on 9/17/2015 was grits, wheat toast, scrambled eggs, orange juice, coffee and non-fat milk. Patient 7 stated the breakfast was not tasty, the eggs were cold and there was no meat. On 9/17/15 at 9:00 a.m., observed second tray being prepared in the kitchen for Patient 7. The patient's tray card read, "Diabetic Salt Restricted 1500 K cal (3CHO choices/meal 1200-1500 calorie). Patient 7 Received wheat toast, grits, non-fat milk, and orange juice for breakfast. When asked why the patient received the same items as was on the first tray, the Dietary Supervisor replied, "alternative items to for food orders is coming in today".

On 9/17/15 at 9:10 a.m., the dietary aide reported that Patient 7 did not receive meat for the breakfast tray because they(hospital) did not have low sodium bacon and no other meat choice was available.

Based on record review, interview, and review the hospital's policies and procedures, the Registered Nurse failed to provide comprehensive assessments and develop nursing care plans for patients admitted for inpatient services for 12 of 20 patient charts reviewed for care plans (Patient 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 4, 2, and 1), and no nursing progress notes for 2 of 20 patients (Patent 6 and 8), and failed to document critical physician ordered values on 2 of 20 patients. (13 and 20)

The findings are:

On 09/17/15 at 1:10 p.m., review of Patient 11's chart revealed the patient was admitted as an inpatient from 06/06/15 through 06/07/15 and there was no nursing care plan developed implemented for the patient.

On 09/17/15 at 1:35 p.m., review of Patient 12's chart revealed the patient was admitted as an inpatient from 06/12/15 through 06/17/15 and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 2:22 p.m., review of Patient 13's chart revealed the patient was admitted as an inpatient from 06/17/15 through 06/19/15 and there was no documentation of a daily review of the patient's nursing care plan by a registered nurse.

On 09/17/15 at 2:45 p.m., review of Patient 14's chart revealed the patient was admitted as an inpatient from 06/21/15 through 06/26/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:07 p.m., review of Patient 16's chart revealed the patient was admitted as an inpatient from 07/02/15 through 07/03/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:26 p.m., review of Patient 17's chart revealed the patient was admitted as an inpatient from 07/09/15 through 07/13/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:35 p.m., review of Patient 18's chart revealed the patient was admitted as an inpatient from 07/10/15 through 07/13/15, and there was no nursing care plan developed and implemented for the patient during the admission.

On 09/17/15 at 3:50 p.m., review of Patient 19's chart revealed the patient was admitted as an inpatient from 07/10/15 through 07/12/15, and there was no nursing care plan developed and implemented during the patient's admission.

On 09/17/15 at 4:05 p.m., review of Patient 20's chart revealed the patient was admitted as an inpatient from 07/15/15 through 07/17/15, and there was no nursing care plan developed and implemented during the patient's admission.

On 09/17/15 at 4:15 p.m., the Clinical System Coordinator stated, "I can't lie. If it's not there, then it's not there. They should have been done and that is an eye opener and will need to get addressed and fixed".

On 09/19/15 at 10:15 a.m., review of Patient 4's chart revealed the patient was admitted from 08/01/2015 through 08/06/2015 and there was no care plan developed and implemented for the patient during this admission.
On 09/16/2015 at 2:00 p.m., review of Patient 2's chart revealed the patient was admitted on 07/28/2015 and discharged on 08/01/2015 with a diagnosis Diabetes. Review of the patient's chart revealed there was no plan of care developed or implemented for the patient although the patient had an identified wound to the left heel and required the insertion of a Foley catheter.

On 9/16/2015 at 2:20 p.m., review of Patient 1's chart revealed the patient was admitted on 7/20/15 and discharged on 07/23/15 with a diagnosis of Dehydration. Review of the patient's chart revealed there was no nursing plan of care although the patient was ordered intravenous fluids of D 5 NS (Normal Saline) to infuse at 100 cc(cubic Centimeters) an hour and daily weights. There was also no documentation of the intravenous fluids infusion intake which skewed the assessment of the patient's fluid balance.



On 09/17/15 at 2:22 p.m., review of Patient 13's chart revealed Patient 13 was admitted on 06/17/15 through 06/19/15 with the diagnosis of dehydration. Patient 13's admission orders stated daily weights. Further review of the chart revealed there were no daily weights documented for this admission.

On 09/17/15 at 4:05 p.m., review of Patient 20's chart revealed Patient 20 was admitted on 07/15/15 through 07/17/15 with the diagnosis of "uncontrolled diabetes mellitus". Patient 20 had physician orders for "insulin regular (Humulin R Sliding Scale Low Dose Algorithm) "QIDACHS". Further review revealed that Pt 20 received only received Fasting Blood Sugars (FSBS) at 5:00 a.m. on 07/15/15, 5:55 a.m. on 07/15/15, 8:44 p.m. on 07/15/15, 6:00 a.m. on 07/16/15, 8:38 p.m. on 07/16/15, and 8:38 p.m. on 07/16/15.

On 09/18/15 at 10:40 a.m., review of Patient 8's chart revealed the patient was admitted on 08/21/15 through 08/25/15 with Septic Wound. There were missing nursing progress notes for 08/21/15 - 08/25/15.

On 09/18/15 at 11:10 a.m., review of Patient 6's chart revealed there were no nursing notes charted from 08/11/15- 12/15/15.

On 09/16/2015 at 2:00 p.m., review of Patient 2's chart revealed the patient was admitted on 07/28/2015 and discharged on 08/01/2015 with a diagnosis Diabetes. Review of the patient's chart revealed there was no plan of care developed or implemented for the patient although the patient had an identified wound to the left heel and required the insertion of a Foley catheter.

On 9/16/2015 at 2:20 p.m., review of Patient 1's chart revealed the patient was admitted on 7/20/15 and discharged on 07/23/15 with a diagnosis of Dehydration. Review of the patient's chart revealed there was no nursing plan of care although the patient was ordered intravenous fluids of D 5 NS (Normal Saline) to infuse at 100 cc(cubic Centimeters) an hour and daily weights. There was also no documentation of the intravenous fluids infusion intake which skewed the assessment of the patient's fluid balance.



31395

Based on patient record review, interview, and review of the facility policy and procedure, the hospital failed to ensure its Registered Nurses developed and implemented nursing care plans, updates care plans daily, and identify patient needs for 13 of 20 closed patient records (Patient 1, 2, 4, 8, 11, 12, 13, 14, 16, 17, 18, 19, and 20) , and failed to complete a comprehensive nursing assessment for 2 of 20 patient charts reviewed. (Patient 14 and 19)

The findings are:

On 09/17/15 at 1:10 p.m., review of Patient 11's chart revealed the patient was admitted as an inpatient from 06/06/15 through 06/07/15 and there was no nursing care plan developed implemented for the patient.

On 09/17/15 at 1:35 p.m., review of Patient 12's chart revealed the patient was admitted as an inpatient from 06/12/15 through 06/17/15 and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 2:22 p.m., review of Patient 13's chart revealed the patient was admitted as an inpatient from 06/17/15 through 06/19/15 and there was no documentation of a daily review of the patient's nursing care plan by a registered nurse.

On 09/17/15 at 2:45 p.m., review of Patient 14's chart revealed the patient was admitted as an inpatient from 06/21/15 through 06/26/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:07 p.m., review of Patient 16's chart revealed the patient was admitted as an inpatient from 07/02/15 through 07/03/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:26 p.m., review of Patient 17's chart revealed the patient was admitted as an inpatient from 07/09/15 through 07/13/15, and there was no nursing care plan developed and implemented for the patient.

On 09/17/15 at 3:35 p.m., review of Patient 18's chart revealed the patient was admitted as an inpatient from 07/10/15 through 07/13/15, and there was no nursing care plan developed and implemented for the patient during the admission.

On 09/17/15 at 3:50 p.m., review of Patient 19's chart revealed the patient was admitted as an inpatient from 07/10/15 through 07/12/15, and there was no nursing care plan developed and implemented during the patient's admission.

On 09/17/15 at 4:05 p.m., review of Patient 20's chart revealed the patient was admitted as an inpatient from 07/15/15 through 07/17/15, and there was no nursing care plan developed and implemented during the patient's admission.

On 09/17/15 at 4:15 p.m., the Clinical System Coordinator stated, "I can't lie. If it's not there, then it's not there. They should have been done and that is an eye opener and will need to get addressed and fixed".

Facility Policy and Procedure, titled, "Assessment, Planning and Evaluating Patient Needs and Nursing Care", reads, "... Initial Assessment- Baseline assessment by the RN/LPN that occurs upon admission to the healthcare system...III. B. The RN is also responsible for the plan of care and selection of nursing interventions and evaluation of patient outcome...IV. Each patient requiring care can expect an initial baseline assessment by a RN within 8 hours of admission...VI. Patients should be re-assessed by a registered nurse at a minimum of every shift...VIII. The RN identifies patient care needs and initiates the plan of care within 8 hours of arrival to unit for admission."

Hospital Nursing Department Policy #ND007 with an effective date of 09/12/2002, titled, Assessment, Planning, and Evaluating Patient Needs and Nursing Care, reads, B. " The RN (Registered Nurse) is also responsible for the plan of care and selection of nursing interventions and evaluation of patient outcome, either by direct care or delegation of assignments." and "VIII. Care Planning: The RN identifies patient care needs and initiates the plan of care within eight (8) hours of arrival to unit for admission or observation and prior to operative or invasive procedures".
On 09/17/15 at 2:45 p.m., review of Patient 14's chart revealed the patient was admitted on 06/21/15 with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD)/Congestive Heart Failure (CHF). Review of the patient's the initial nursing assessment showed the patient's respiratory system assessment was not documented.

On 09/17/15 at 3:50 p.m., review of Patient 19's chart revealed the patient was admitted on 07/10/15 with the diagnosis of Pneumonia. Review of the patient's initial nursing assessment showed the patient's respiratory system assessment was not documented.

On 09/17/15 at 3:51 p.m., the Clinical System Coordinator revealed that assessments are performed according to the complaint and the reason the patient is being admitted.









36295

On 09/19/15 at 10:15 a.m., review of Patient 4's chart revealed the patient was admitted from 08/01/2015 through 08/06/2015 and there was no care plan developed and implemented for the patient during this admission.
On 09/19/15 at 10:30 a.m., during an interview of Infection Control Nurse, the Infection Control Nurse verified the finding.
On 09/18/15 at 10:40 a.m., review of Patient 8's chart revealed the patient was admitted on 8/21/15 through 8/25/15 with a diagnosis of Septic Wound. There were no physician orders for wound care left hip.
On 09/18/15 at 12:20 p.m., the Infection Control Nurse verified the findings.

Based on patient record review and interview, the hospital staff failed to document the respiratory status and wound status on the patient's initial assessment of health status for 3 of 20 (Patient 2, 14, and 19)closed patient records reviewed and there was no discharge summary or discharge diagnosis for 2 of 20 closed patient records reviewed. (Patient 2 and 7), and no physician orders for wound care or for insertion of a Foley catheter for 2 of 20 patient records reviewed. (Patient 2 and 8)

The findings are:

On 09/17/15 at 2:45 p.m., review of Patient 14's chart revealed the patient was admitted on 06/21/15 with the diagnoses of Chronic Obstructive Pulmonary Disease (COPD)/Congestive Heart Failure (CHF). Review of the patient's the initial nursing assessment showed the patient's respiratory system assessment was not documented.

On 09/17/15 at 3:50 p.m., review of Patient 19's chart revealed the patient was admitted on 07/10/15 with the diagnosis of Pneumonia. Review of the patient's initial nursing assessment showed the patient's respiratory system assessment was not documented.

On 09/17/15 at 3:51 p.m., the Clinical System Coordinator revealed that assessments are performed according to the complaint and the reason the patient is being admitted.

Facility Policy and Procedure, titled, "Assessment, Planning, and Evaluating Patient Needs and Nursing Care", reads, "...Assessment-The systematic collection and analysis of pertinent data to determine needs...








18581

On 09/16/2015 at 2:00 p.m., review of Patient 2's chart revealed the patient was admitted on 07/28/2015 and discharged on 08/01/2015 with a diagnosis Diabetes. Review of the patient's chart revealed although a wound on the patient's left heel was identified in the initial nurse's assessment, there was no other assessment of the wound documented related to size, exudates, etc. Review of the patient's chart revealed the nurse inserted a Foley catheter but there were no physician orders for the insertion of the Foley catheter or for wound care. Review of the patient's discharge summary revealed there was no discharge diagnosis(es) identified.

On 9/16/2015 at 2:20 p.m., review of Patient 1's chart revealed the patient was admitted on 7/20/15 and discharged on 07/23/15 with a diagnosis of Dehydration. Review of the patient's chart revealed there was no nursing plan of care although the patient was ordered intravenous fluids of D 5 NS (Normal Saline) to infuse at 100 cc(cubic Centimeters) an hour and daily weights. There was also no documentation of the intravenous fluids infusion intake which skewed the assessment of the patient's fluid balance.


36295

On 09/18/15 at 9:50 a.m., review Patient 7's chart revealed the patient was admitted on 8/17/15 through 8/21/15 for Urosepsis. There was no discharge summary on the patient's chart.

On 09/18/15 at 10:40 a.m., review of Patient 8's chart revealed the patient was admitted on 8/21/15 through 8/25/15 with a diagnosis of Septic Wound. There were no physician orders for wound care left hip.
On 09/18/15 at 12:20 p.m., the Infection Control Nurse verified the findings.

Based on patient chart review and interview, the hospital failed to ensure that the patient's History and Physical (H&P) and nutritional and social services consults were completed for 8 of 19 closed patient records reviewed. ( Patient 10, 11, 12, 13, 14, 17, 18, 19, and 20)

The findings are:

On 09/17/15 at 1:10 p.m., review of Patient 11's chart revealed Patient 11 was admitted from 06/06/15 through 06/07/15. There was no documentation of the social and family history on the patient's H&P or of the social services consult.

On 09/17/15 at 1:35 p.m., review of Patient 12's chart revealed Patient 12 was admitted from 06/12/15 through 06/17/15. There was no documentation of the social service consult or nutritionist consult.

On 09/17/15 at 2:22 p.m., review of Patient 13's chart revealed Patient 13 was admitted from 06/17/15 through 06/19/15. There was no documentation of the social service consult.

On 09/17/15 at 2:45 p.m., review of Patient 14's chart revealed Patient 14 was admitted from 06/21/15 through 06/26/15. There was no documentation a H&P or of the social services and nutritionist consults.

On 09/17/15 at 3:26 p.m., review of Patient 17's chart revealed Patient 17 was admitted from 07/09/15 through 07/13/15. There was no documentation of the social and family history on the H&P or documentation of the Home Health consult or the social services consult.

On 09/17/15 at 3:35 p.m., review of Patient 18's chart revealed Patient 18 was admitted from 07/10/15 through 07/13/15. There was no documentation of a social and family history on the patient's H&P.

On 09/17/15 at 3:50 p.m., review of Patient 19's chart revealed Patient 19 was admitted from 07/10/15 through 07/12/15. There was no documentation of the social and family history on the patient's H&P.

On 09/17/15 at 4:05 p.m., review of Patient 20's chart revealed Patient 20 was admitted from 07/15/15 through 07/17/15. There was no documentation of the patient's social history on the H&P or documentation of consults for Home Health and the nutritionist.

On 09/18/15 at 10:15 a.m. the Social Worker revealed that "I usually look through all orders or the nurses will reach out to me and let me know that a patient need a consult. Then I will perform the consult and chart it under case management or swingbed. I don't know why it isn't there."






36295

On 09/18/15 at 12:20 p.m., review of Patient 10's chart revealed the patient was admitted from 09/03/15 - 09/05/15 with a diagnosis of Pancreatitis. There was no History and Physical on the patient's chart.

On 9/16/2015 at 2:00 p.m., review of Patient 2's chart revealed the patient was admitted on 07/28/2015 and discharged on 08/01/2015 with a diagnosis Diabetes. Review of the medical progress notes revealed the only medical progress note was dated 7/30/2015.

On 9/16/2015 at 2:20 p.m., review of Patient 1's chart revealed the patient was admitted on 7/20/15 and discharged on 07/23/15 with a diagnosis of Dehydration. Review of the patient's chart revealed there were no physician progress notes from 7/20/15 through 7/23/15.


31395

Based on patient record review and interview, the hospital failed to ensure patient admissions had medical progress notes for 10 of 20 closed patient records reviewed. (Patient 1, 2, 4, 6, 7, 8, 9, 12, 13 and 20)

The findings are:

On 09/17/15 at 1:35 p.m., review of Patient 12's chart revealed Patient 12 was admitted from 06/12/15 through 06/17/15 . Further review revealed that Pt 12 did not have evidence of physician progress notes documented for the date of 06/14/15.

On 09/17/15 at 2:22 p.m. review of Pt 13's chart revealed that Pt 13 was admitted on 06/17/15 through 06/19/15 with the diagnosis of dehydration. Pt 13 admit orders stated daily weights. Further review revealed no daily weights documented for this admission.

On 09/17/15 at 4:05 p.m. review of Pt 20's chart revealed that Pt 20 was admitted on 07/15/15 through 07/17/15 with the diagnosis of "uncontrolled diabetes mellitus". Pt 20 had orders for "insulin regular (Humulin R Sliding Scale Low Dose Algorithm) "QIDACHS". Further review revealed that Pt 20 received FSBS at 5:00 a.m. on 07/15/15, 5:55 a.m. on 07/15/15, 8:44 p.m. on 07/15/15, 6:00 a.m. on 07/16/15, 8:38 p.m. on 07/16/15, and 8:38 p.m. on 07/16/15.

On 09/17/15 at 4:15 p.m. the Clinical System Coordinator revealed that "I'm not sure why the progress note wasn't done".



36295

On 09/18/15 at 9:50 a.m., review Patient 7's chart showed Patient 7 was admitted on 08/17/15 through 08/21/15 for Urosepsis. There were no physician progress notes for 08/17/15.

On 09/18/15 at 10:15 a.m., review Patient 4's chart showed the patient was admitted on 08/01/15 through 08/06/15 with Right Leg Cellulitis. There were no physician progress notes for 08/03/15.

On 09/18/15 at 10:40 a.m., review of Patient 8's chart revealed the patient was admitted on 08/21/15 through 08/25/15 with Septic Wound. There were missing nursing progress notes for 08/21/15 - 08/25/15.

On 09/18/15 at 11:10 a.m., review of Patient 6's chart revealed there were no nursing notes charted from 08/11/15- 12/15/15.

On 09/18/15 at 12:10 a.m., review of Patient 9's chart revealed there was no physician progress notes from 09/02/15 - 04/15/15.

On 09/18/15 at 12:15 p.m., the Infection Control Nurse verified the findings.

Based on review of the hospital's contracts, review of the hospital's policies and procedures, and interview, the hospital failed to show evidence that the nursing staff was in-serviced and trained on its policies and procedures for Organ, Tissue, and Eye procurement.

The findings are:

On 09/05/15 at 9:05 a.m., review of the hospital's policy and procedure, titled, AP046 Organ And Tissue Donation Policy", with a revision date of 09/2005, reads, "VII. Review of Records and Staff Education: 3. The hospital works cooperatively with LifePoint in educating staff on donation issues." On 09/05/15 at 09:30 a.m., during an interview with Registered Nurse(RN) 4, RN stated, "there is no Organ Procurement telephone number posted at the desk. RN 4 reported that he/she had received no education or training on organ donation procedures. Review of random staff personnel records and the hospital's annual skills competency training revealed organ donation was not listed in the training.

Based on record reviews, interviews, review of the activities calendar, job descriptions, patient care plans, the hospital failed to ensure an active activity program with oversight by a qualified individual.

The findings are:

Cross Reference to C 0385: The hospital failed to provide evidence of an active program for activities for its swing bed population that lacked comprehensive assessments of swing bed patient's regarding their activity choices, lacked a qualified employee to supervise the program, lacked an interdisciplinary group of personnel for developing a plan of care and failed to include activities in the patient's plan of care.

Cross Reference to C 0395: The Activity Program Director failed to provide comprehensive assessments and develop comprehensive care plans for activities for patients admitted for swing bed services for 6 of 6 swing bed patients. (Patient 1, ,2 3, 4, 5, and 6)

Based on record review, interview, and review of the hospital's policies and procedures, the Registered Nurse failed to provide comprehensive assessments and develop comprehensive nursing care plans for patients admitted for swing bed services for 6 of 6 swing bed patients and the Activity Program Director failed to provide comprehensive assessments and develop comprehensive care plans for activities for patients admitted for swing bed services for 6 of 6 swing bed patients. (Patient 1, ,2 3, 4, 5, and 6)


The findings are:


On 9/15/2015 at 0915 a.m., review of Patient 1's chart showed the patient was admitted on 09/03/15 status post an open reduction right femur repair for rehabilitation services. Review of the patient's chart revealed the patient received oxygen, blood glucose monitoring, identified as a fall risk, required wound assessment, and was at risk for skin break down. Review of the patient's plan of care revealed the only problem documented was,"Impaired Physical Mobility Plan of Care".

On 9/15/2015 at 10:00 a.m., review of Patient 2's chart revealed the patient was admitted on 09/08/2015 with status post cervical surgery. Review of the patient's chart revealed the patient's care plan only addressed "Impaired Physical Mobility Plan of Care". Review of the patient's chart revealed diabetes, blood glucose monitoring, and the use of BiPap as the patient issues that were not included on the patient's plan of care. Neither activity nor discharge planning was addressed on the patient's plan of care.

On 09/15/2015 at 10:30 a.m., review of Patient 3's chart revealed the patient was admitted on 08/25/15 for hip fracture. Review of the patient's plan of care revealed the only problems addressed were "Impaired Physical Mobility Plan of Care" and " Impaired Skin Integrity". Review of the patient's chart showed impaired cognitive status related to Dementia, seizures, and Gastroesophageal reflux as care issues that were not addressed on the patient's plan of care. There was no plan of care for activities, discharge, or for nutrition although a nutritional consult was ordered.

On 09/15/2015 at 11:00 a.m., review of Patient 4's chart revealed the patient was admitted on 09/09/15 following surgery for strengthening. Review of the patient's plan of care revealed the only problem was "Impaired Physical Mobility Plan of Care". Review of the patient's chart revealed the wife reported to nursing that the patient had showed some confusion, paranoia, and hallucinations since surgery. None of this was addressed in the patient's plan of care as well as there was no plan for discharge or for activities.

On 09/15/2015 at 1:00 p.m., review of Patient 5's chart revealed the patient was admitted on 09/09/2015 for strengthening. Review of the patient's plan of care showed only "Impaired Physical Mobility Plan of Care". Review of the patient's chart revealed the patient received CPAP, had Diabetes, and had Chronic Obstructive Pulmonary Disease, but there were no problems on the patient's plan of care that addressed the issues as well as no plan of care for discharge planning or activities.

On 9/15/2015 at 1:30 p.m., review of Patient 6 's chart revealed the patient was admitted on 09/08/2015 for post surgery for physical therapy strengthening and assistance with activities of daily living. Review of the patient's plan of care revealed the only problem identified in the plan of care was "Impaired Physical Mobility Plan of Care". Review of the patient's chart showed the patient required wound care, was a fall risk, at risk for skin break down, had periods of nausea, and received oxygen therapy which were not addressed in the patient's plan of care as well as neither discharge planning nor activities were not addressed.

On 09/15/ 2015 at 3:30 p.m., during an interview with the Director of Nurses, the Director of Nurses reviewed the patient's electronic medical records. The Director of nurses asked Registered Nurse 3 about the patient care plans. Registered Nurse 3 reported that there was only one problem entered for each swing bed patient because the nursing staff had been taught that the "Immobility" problem was the only problem that should be placed in the computer for the patients in swing beds.

Based on patient record review and interview, the hospital failed to complete comprehensive assessments and develop comprehensive care plans by an interdisciplinary team for 6 of 6 patients in the hospital's swing bed program.

The findings are:

On 09/17/15 at 1:00 p.m., during an interview with the Occupational Therapist and on 9/18/2015 at 09:45 a.m. with the Quality Manager, the Occupational Therapist and the Quality Manager verified that there is no interdisciplinary team meetings for the purpose of developing individualized patient care plans. Review of 6 of 6 patient charts in the swing bed program revealed that none of the patient charts had a plan of care that addressed activities.

Based on observations, interviews, and record reviews, review of the hospital's patient menus, and review of the hospital's personnel files, the hospital failed to ensure its supervisory dietary staff were knowledgeable in the provision of physician ordered therapeutic diets required to meet the nutritional needs of the patient, knowledgeable in developing menus that meet the therapeutic as well as substitution requirements for individualization of patient diets, and failed to ensure that the hospital provided qualified staff responsible for the supervision of its dietary services.

The findings are:


On 9/14/15 at 12:15 p.m., observation of the food service line revealed the Dietary Supervisor preparing the lunches for 6 patients. Food items were spaghetti noodles, a red meat sauce, mixed vegetables, bread, and prepackaged jello. Observation revealed the Dietary supervisor wore the same blue gloves to prepare the patient food trays that he/she had worn throughout the tour of the dietary area. The Dietary Supervisor did not use utensils designed for food portioning as the different items were placed on each of the 6 patient plates. There were no other food items prepared for substitution items. When asked about food substitutions, the Dietary Supervisor reported that he/she would take a frozen chicken breast out of the freezer and prepare that for the patient and stated that it would take about 20 minutes to prepare the frozen chicken breast.

On 9/14/15 at 4:00 p.m., review of a book with various menus was brought for review of the menus. The menus in the book were dated 2014 and the food items that were served for the lunch meals were different from the items listed on the menu in the book for 9/14/2014 lunch menu. It was determined that the book of menus dated 2014 was no longer used. The Dietary Supervisor submitted the menu for the week.

The weekly menu showed that for each morning during the week of the survey the breakfast was listed as: eggs, sausage, bacon, grits, coffee, milk and juice. The Dietary Supervisor reported that each patient received that for their breakfast tray. When the Dietary Supervisor was asked if there were any menus for therapeutic diets or substitutions, the dietary supervisor reported that there were none. The Dietary Supervisor stated, "I just hold the salt and pepper on diabetics and patients that should not have salt".

On 9/15/15 at 10:35 a.m., during an interview with Registered Dietician(RD), the RD reported that she was aware of the issues in the dietary department but he/she had only just started 2 weeks ago. The RD stated that he/she was responsible for Cardiac Rehab patients, Home Health Care patients, and Diabetic education, but he/she was not directly responsible for the supervision of the kitchen.

On 9/15/15 at 12:20 p.m., observation of the patient food trays delivered to the medical surgical unit showed 5 of the 6 patient's received a breaded fish, spinach, bread roll, and milk. 1 of 6 patients received a breaded chicken breast, spinach, bread roll, and milk. The tray cards sent with each patient tray had the correct ordered diet for each tray although the diet served was a regular diet. Three of the 6 patients were ordered therapeutic diets but received regular diets.

Patient 1 was admitted on 09/03/15 with a physician diet for Diabetic. The patient received a regular diet on 09/15/2015 for the breakfast and lunch meals.

Patient 2 was admitted on 09/08/2015 with a physician diet order for Diabetic Diet. Patient 2 received a regular diet for the breakfast and lunch meal.

Patient 6 was admitted on 09/09/15 with a physician diet order for Low Sodium, 2 gram Na, Salt Restricted Diet. Patient 6 received a regular diet for the breakfast and lunch meal on 09/15/2015.

On 9/15/15 at 12:20 p.m.., Dietary Supervisor revealed he/she had no formal training for food services in a health care facility and stated, "No guidelines to follow".

On 9/15/15 at 1:00 p.m., review of the Dietary Supervisor's personnel chart revealed no documentation of required education, training, or experience as specified on the hospital's job description and no previous experience in a health care facility was identified on the Dietary Supervisor's employment application met the requirements. Review of the Food Service supervisor's job summary and specifications showed,"Education: Completion of Dietary Managers Course or 2 to 3 years experience in institutional service; Experience: 2 - 3 years experience in food preparation and supervision; Licensure, Registry or Certification Required: Dietary Manager's Certificate, Heart saver CPR.
Special Training: Must attend general hospital mandatory training, and additional department requirements on an annual basis. Must possess knowledge and skills necessary to serve patients of all ages including infants, pediatrics, adolescents, adults."

On 9/15/15 at 1:50 p.m., the Registered Dietitian submitted an alternate menu but reported that the items listed on the alternate menu were not available as of yet and he/she is still working on the list.