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Based on interview, record review and policy review, the facility failed to:
-Ensure there was an effective, ongoing, hospital-wide, data driven Quality Assurance/Performance Improvement (QAPI) program, responsible to the Governing Body, for nine departments (Emergency, Out-Patient, Respiratory, Rehabilitation, Housekeeping, Nursing, Swing Bed, Discharge Planning and Maintenance), which could improve patient care (A0267 and A0309); and failed to
-Implement Performance Improvement projects (A297)

The cumulative effect of this systemic practice resulted in the facility's non-compliance with 42 CFR (Code of Federal Regulations) 482.21 Condition of Participation: Quality Assessment and Performance Improvement Program.

Based on record review and interview the facility failed to ensure two (Staff BB and Staff CC) of ten employees had the required certifications for their job classification. The facility census was six.

Findings included:

1. Review of Staff BB's (a certified nurse assistant) job description showed the following:
- This positon required a current cardiopulmonary resuscitation (CPR-a certification enabling one to perform an attempt to re-start the heart).

Review of Staff BB's personnel record showed the following:
- Staff BB's CPR certificate expired on 10/20/11.

Staff failed to provide a current CPR certificate prior the survey exit, even though requested.

2. Review of Staff CC's (a registered nurse) job description showed the following:
- This positon required a current CPR certification.

Review of Staff CC's personnel record showed the following:
- Staff CC's CPR certificate expired in 1/12.

During an interview on 02/09/12, at 3:42 PM, Executive Assistant, Staff B stated the managers were to track the due dates of applicable certificates and notify the staff member to obtain. Staff, in these cases, were unaware the certificates had expired. Staff failed to provide a current CPR certificate prior the survey exit, even though requested.

Based on interview and record review the facility failed to ensure contracted services were provided in a safe and effective manner by not implementing a mechanism to evaluate each service under the Quality Assurance Performance Improvement Plan. The facility census was six.

Findings included:

1. Record review of the facility Quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed indicators for contracted services were not included.

Record review of the facility Quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed the following:
-The Board of Directors provides leadership for the Quality Improvement process by supporting and guiding implementation of Quality Improvement activities at the hospital.
-The Board of Directors reviewed, evaluated, and approved the Quality Improvement Plan annually.

2. During an interview on 02/07/12 at 11:15 AM Staff M Clinic Admissions Manager and Hospital Quality Assurance stated that the Quality Assurance Plan did not include contracted services. There were not quality indicators that tracked the safety and effectiveness of the contracted services.

3. Record review of the list provided by the facility of contracted services showed approximately 151 services that the facility had contracts with, including Bio-Medical Services, Physician Services in the Emergency Department, Lab/Autopsy, Organ Procurement, Lab equipment and supplies, Blood and Blood Products, Olympus for maintenance of scopes [Tubes with a camera that are used to go down and look at the stomach or go up to look at the colon.) Emergency Department documenting system, and internet services

Based on interview and record review the facility failed to provide "An Important Message from Medicare" (IM letter) within two days of admission or in advance of the patient's discharge for four patients/patient representatives when appropriate, (#11, #13, #4 and #6) of four records reviewed. The facility census was six.

Findings included:

1. Record reviews of Patient #11's and Patient #13's medical record showed no IM letters.

2. During an interview on 02/08/12 at 11:25 AM Staff O, Supervisor of Admissions stated that the facility failed to give Medicare patients an IM letter for at least a year.

During an interview on 02/08/12 at 1:30 PM Patient #6, who had Medicare, stated he did not receive the IM letter.

During an interview on 02/08/12 at 1:45 PM Patient #4, who had Medicare, stated she did not receive the IM letter.

Based on interview and record review, the facility failed to identify the difference between a complaint and grievance, failed to have a policy that identifes the components of, and how to specifically handle a grievance from receipt through resolution. The facility failed to identify any grievances for the months of August 1, 2011 through February 1, 2012. Two of five complaints were reviewed for compliance with this regulation (Patients #19 and #20). The facility census was six.

Findings included:

1. Review of a facility policy titled, "Patient Grievance Procedure," reviewed 12/95, showed the following:
- Patients, family or significant others will be given the opportunity to make a grievance, complaint or concern known to the social worker;
- The social worker will serve as an advocate in regard to complaints as appropriate;
- Patients, family or significant others will be made aware of their right to file a grievance.

Review of a facility policy titled, "Complaint Process," reviewed 10/07, showed the following:
- Upon learning of a complaint, the complaint will be directed to the most immediately available management team member;
- Should the patient/visitor not be satisfied with the outcome of the Complaint Process, he/she may lodge a grievance with the state licensure surveyors.

The facility staff failed to identify timeframes for completion of investigations, failed to identify the difference between a complaint and grievance, how an investigation was to be conducted, what to include, and respond to grievance investigations.

2. Review of a complaint, dated 11/09/11, showed discharged Patient #19 complained that pain medications had not been administered timely.

The complaint was not addressed until 11/17/11; therefore, making it a grievance (could not be resolved at point of service).

3. Review of a complaint, dated 11/15/11, showed discharged Patient #20 complained about a specific staff member being inappropriate with his/her actions.

Staff failed to document any response/action to this complaint, other than counseled staff member (no date listed).

4. During an interview on 02/08/12 at 3:22 PM, the Executive Assistant, Staff B, stated she had no knowlede of any grievances related to patients, for the prior six months. Staff B stated the facility had no social worker to handle complaints/grievances per the facility policy.

During an interview on 02/08/12, at 2:56 PM, the Director of Nurses (DON), Staff A, stated the complaint form was completed and the appropriate manager investigates. Staff A was not familiar with the difference between a complaint and grievance.

During an interview on 02/08/12, at 4:02 PM, Patient #7 (alert and oriented, and capable of reading), stated she had not been informed of how to file a complaint/grievance. Patient #7 had not read brochures given at admission (the phone number extension to start the grievance process is in the brochure).

During an interview on 02/09/12, at 10:00 AM, the DON stated they currently had no social worker.

Based on interview and record review, the facility failed to notify two of two patients of a resolution to their grievance. Two of five complaints were reviewed for compliance with this regulation (Patients #19 and #20). The facility census was six.

Findings included:

1. Review of facility policies titled, "Patient Grievance Procedure," reviewed 12/95, and, "Complaint Process," reviewed 10/07, failed to address responses to complaint/grievance investigations.

2. Review of a grievance (facility classified as a complaint), dated 11/09/11, showed discharged Patient #19 complained that pain medications had not been administered timely.

Staff failed to respond in writing to the complainant with a decision/resolution, steps taken to investigate the grievance, date of completion, and contact person.

3. Review of a grievance (facility classified as a complaint), dated 11/15/11, showed discharged Patient #20 complained about a specific staff member being inappropriate with his/her actions.

Staff failed to respond in writing to the complainant with a decision/resolution, steps taken to investigate the grievance, date of completion, and contact person.

Based on observation, interview and record review the facility failed to provide personal privacy for three (#2, #5 and #32) of three patients observed. The facility census was six.

Findings included:

1. Review of facility policy titled, "Patient Rights and Responsibilities," effective 06/05, showed the patient had the right to privacy and confidentiality and to be interviewed and examined in surroundings designed to assure reasonable privacy.

2. Observation on 02/09/12 at 9:45 AM showed Staff W, Certified Nurse Assistant (CNA), came to the door of Patient #2's room and stood outside the room and asked the patient where her wound was instead of putting on an isolation gown and coming into the room to talk with the patient. The patient was in contact isolation due to a possible wound infection.

During an interview on 02/09/12 at 9:50 AM Patient #2 stated that she would prefer the CNA put on her gown and come in to talk about medical issues instead of standing at the door.

During an interview on 02/09/12 at approximately 9:52 AM Staff W, stated that she does not always put on the gloves, gown, and mask that are required when a patient is in contact isolation. Staff W stated that she stands by the door and talks instead of going into the room to ask the patient information.

Observation on 02/09/12 at 10:00 AM showed the hall where Staff W stood was a main hallway from administration and pharmacy down to the kitchen. There was a hall off this main hall that lead to the x-ray, lab, and emergency department. Staff and visitors could access the halls.

3. Review of Patient #5's nursing admission history, dated 02/06/12, showed the patient was admitted, via the emergency department, on that date with a complaint of a swollen, red face (right side), a toothache, and a swollen, hard area on the right foot (possible infection). The patient was alert and oriented.

Observation on 02/06/12 at 1:40 PM showed Patient #5 on contact isolation as indicated by a sign outside her door stating such. As the surveyor was donning personal protective equipment (PPE-infection control gown and gloves) in order to enter the room, Physician Staff DD stood outside the patient's doorway and asked the patient and Registered Nurse (RN), Staff CC, already in the patient's room, questions about the patient's condition. Questions included was the patient's foot red or hot, did she have a fever, double vision, blurriness, when did illness begin, etc. Physician Staff DD told the nurse to do a throat culture. Physician Staff DD failed to introduce himself, or explain why he was there asking questions of the patient and nurse. RN CC acted as the assessment liasion for the physician, from the doorway. The patient asked the surveyor who this man (the physician) was, and what he was doing.

During an interview on 02/06/12 at 1:53 PM, RN CC confirmed the identity of physician DD, and that he was this patient's assigned physician while in this hospital.

During an interview on 02/07/12 at 9:54 AM, Patient #5, and a family member, stated they were not crazy about Physician DD not coming into the room to do the patient's assessment. The patient and family member mentioned the lack of privacy and confidentiality afforded them.

During an interview on 02/07/12 at 2:37 PM, the Director of Nurses (DON), RN A, stated she agreed this type of interview/assessment by a physician was not acceptable. The physician should do assessments in the patient room, not in the hallway.

4. Record review of Patient #32's medical record showed he was admitted to the facility on 02/02/12 with diagnoses of shortness of breath, swelling of lower limbs and change in mental status per History and Physical (H & P, dated 02/02/12). It also showed the patient had dementia, Congestive Heart Failure (CHF), and Hypertension (HTN).

Observation on 02/07/12 at 11:32 AM showed multiple nursing staff transferring Patient #32 from his bed to a stretcher. Staff E, RN, told the patient's spouse that they were transferring patient to the stretcher to transport him to the Radiology Department for a scan. In the process of transferring the patient from his bed to the stretcher, part of his body was exposed. Once Staff E noted they were observed from the hallway by a surveyor, she asked another staff to pull the curtain in the room that protected the patient from exposure to persons passing in the hallway.

Observation on 02/07/12 at 11:45 AM showed multiple nursing staff bringing Patient #32 back to his room on the stretcher. Staff returned the patient to his room and did not pull the curtain around his bed again when transferring him from the stretcher to his bed. The patient was exposed again to persons passing in the hallway. After Staff E noted again that they were being observed from the hallway, she asked another staff to pull the curtain so that patient could not be visible from the hallway.


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Based on policy review, observations and staff interview, the facility's staff failed to ensure the confidentiality of patients' medical records were safeguarded and protected from the possibility of unauthorized persons reviewing them. The facility census was six.

Findings included:

1. Record review of the facility's policy titled "Confidentiality/Security," dated 02/12/10 showed the following direction:
-Sac Osage Hospital personnel have a strict obligation to keep in confidence all that pertains to the patient and his/her affairs.
-All reasonable steps must be taken to ensure that a patient's confidential health information, as well as personal affairs, not be disclosed to any person or organization, not even to another staff member expect (should be except) as they have a specific need to know in order to perform a job and then, only the minimum necessary.
-This includes information that is obtained, maintained, used, disclosed, heard or viewed while carrying out their responsibilities.

Record review of the facility's Policy titled "HIM (Health Information Management) Security," dated 02/16/10 showed the following direction:
-Information should be safeguarded in a manner commensurate with its value, sensitivity and criticality.
-There is both legal and moral responsibility to safeguard all information against loss, defacement, destruction, tampering, use by unauthorized persons or through unauthorized access.
-This policy has been set to ensure that confidentiality of the record is maintained, that dissemination of information I (should be is) controlled and that the physical record is safeguarded.
-This policy is applicable to all information created, collected, stored and processed by Sac-Osage Hospital Health Information Management Department.
-This includes any information that is the property of Sac-Osage Hospital, the patient, caregivers, researchers, and any other party, and has been entrusted to Sac-Osage Hospital for use and safekeeping.

Sac-Osage Hospital HIM will respect the rights of the patient with regard to information confidentiality. This information includes, but is not limited to the following:
-Financial information
-Patient information (personal, medical, billing information, etc)
Employee information
-Any person who has access to data in any form is responsible for maintaining the confidentiality of the data.
-These procedures include, but not limited to the following:
Take necessary measures to preserve information confidentiality and privacy.
Maintaining a secure work environment.
Reporting any suspected breach of information security to management.

2. While reviewing the Rehabilitation Department, observations on 02/06/12 at 3:15 PM showed both, Staff T, Physical Therapy Assistant (PTA) and Staff GG, Contracted Registered Physical Therapist, (RPT) left the Department during the same period of time. Observation showed the designated office space was a room within the therapy area without a door. Observation showed a file cabinet inside of the office by the doorway with the keys to the file cabinet hanging in the file cabinet key hole. The door to the department was located by a hall that led outside through an exit door. Further observation showed staff left the drawers unlocked and the drawers contained patients' medical records information.

Record review of the patients' personal information contained in the records included the following:
-Name, address, phone number
-Social security number, date of birth and age
-Diagnoses
-Order for treatment
-Insurance information

3. During an interview on 02/06/12 at 3:15 PM, Staff T stated that he locked the file cabinet drawers at the end of the work day and put the key on a shelf in an unlocked cabinet.

During an interview on 02/07/12 at 3:09 PM, Staff T stated that he did not have a key to his office door. He stated that he left the door unlocked when he went in and out because he would have to find the housekeeper to unlock the door for him each time he needed to get back in. He stated that he inquired about a key and was told that he may have to wait until his probationary period ended before he received a key to his office door.

Based on observation, interview, and record review the facility failed to demonstrate and/or provide evidence the staff had been evaluated for competency in the application of restraints (behavioral or medical). The facility census was six.

Findings included:

1. Review of a facility policy titled, "Use of Restraints," revised 08/07, showed the following:
- The Registered Nurse (RN) assesses the patient to determine applicability of medical versus emergency behavioral restraints;
- Restraints may be applied without an order when the patient may be in danger of harming himself or others;
- One appropriately trained staff member must be present at the bedside when restraint is applied, to observe and ascertain the safe application.

2. During an interview on 02/09/12, at 10:00 AM, the Director of Nurses (DON), Staff A, stated there was no staff member, excluding physicians, qualified/trained to perform the one-hour face-to-face assessment in the event of a behavioral restraint. The DON stated they typically just call the maintenance staff, and/or the local police department, to assist with a violent patient. The DON stated the staff had no specific training to restrain/handle violent patients.

During an interview on 02/09/12, at 11:47 AM, the interim Chief Executive Office (CEO) agreed staff need to be prepared to restrain/treat the violent patient entering the hospital.

During an interview on 02/09/12, at 1:05 PM, the Education Coordinator, Staff N, stated the entire hospital staff review a computer module on restraints/seclusion, and this is completed annually.

3. Observation of the computer module on restraints/seclusion, in its entirety, on 02/09/12, at 3:10 PM, showed no education on how to apply restraints.

4. Review of seven employee files for evidence of restraint competency showed facility staff failed to document/assess restraint application competency on an annual/on-going basis.

Based on observation, interview, and record review the facility failed to demonstrate and/or provide evidence the staff had training that would enhance identification of patient behaviors, events and other factors that may trigger use of a restraint/seclusion. The facility census was six.

Findings included:

1. Review of facility policies titled, "Use of Restraints," revised 08/07, and "Assessment-Behavioral or Emotional Disorders," failed to show any educational information as to how to identify possible causations of behaviors leading to the use of restraints/seclusion.

2. During an interview on 02/09/12, at 10:00 AM, the Director of Nurses (DON), Staff A, stated there was no staff member, excluding physicians, qualified/trained to perform the one-hour face-to-face assessment in the event of a behavioral restraint. The DON stated they typically just called the maintenance staff, and/or the local police department, to assist with a violent patient. The DON stated the staff had no specific training to restrain/handle violent patients.

During an interview on 02/09/12, at 11:47 AM, the interim Chief Executive Office (CEO) agreed staff need to be prepared to restrain/treat the violent patient entering the hospital. The CEO stated mental health/violent patients do come to the facility Emergency Department on occasion.

3. Observation of a computer module on restraints/seclusion (mandated for all staff annually), in its entirety, on 02/09/12, at 3:10 PM, showed no education or training on how to identify/treat any triggering events, or specific needs of the patient population, violent, or otherwise.

4. Review of six employee files for evidence of restraint competency showed facility staff failed to document/assess any provided education related to specific populations and the possible need for restraint application, violent or otherwise.

Based on observation and interview, and record review the facility failed to demonstrate and/or provide evidence the staff had training in first aid in response to patients that required restraint. The facility census was six.

Findings included:

1. Review of facility policies titled, "Use of Restraints," revised 08/07, and "Assessment-Behavioral or Emotional Disorders," failed to show any educational information as to first aid techniques utilized on patients with restraints.

2. During an interview on 02/09/12, at 1:05 PM, the Education Coordinator, Staff N, stated there was no specific first aid training in relation to restraints provided to staff.

3. Observation of a computer module on restraints/seclusion (mandated for all staff annually), viewed in its entirety, on 02/09/12, at 3:10 PM, showed no education or training on first aid techniques utilized on patients with restraints.

4. Review of six employee files, for evidence of restraint first aid training, showed facility staff failed to document/assess any provided education related to first aid for patients with restraints.

Based on observation, interview and record review the facility failed to ensure their visitation policy was updated to reflect reasons for restrictions or nondiscriminatory practices. The facility census was six.

Findings included:

1. Review of a facility policy titled, "Visitors Policy," revised 10/07, showed the following:
- ALL EMPLOYEES must assist in enforcing the Visitors Policy;
- No more than two (2) visitors to a patient at one time;
- Children under 12 may visit only between the hours of 7:00 PM - 8:30 PM (no specific rationale given for this restriction);
- Regular visiting hours are 10:30 AM to 8:30 PM;
The policy failed to include how the staff will be trained to assure appropriate implementation of the visitation policies and avoid unnecessary restrictions on patient's rights.

2. Observation and interview on 02/08/12, at 10:45 AM, showed a sign at the entrance of the hospital showing the above visitation information. Administration Supervisor, Staff O, stated the visitation policy was not included in the patient admission packet.

Observation and interview on 02/08/12, at 4:02 PM, showed Patient #7 had two visitors. Patient #7 stated the visitors were her grandchildren, aged eight and ten (visiting outside policy hours for children). Staff failed to enforce the policy guidelines they did have.

Based on interview and record review the facility failed to implement ongoing, comprehensive, hospital-wide, patient-oriented performance improvement projects for all departments of the hospital. The facility census was six.

Findings included:

1. During an interview on 02/07/12 at 11:15 AM Staff M, Clinic Admissions Manager, and QA (Quality Assurance) for the hospital stated that there were not any performance improvement projects implemented in 2010, 2011, and none for 2012 at this time.

During an interview on 02/07/11 at 3:03 PM, Staff T, Physical Therapy Assistant/Director, stated that he had only been at the facility for one and one half months, but had attended Performance Improvement (PI) meetings. He stated that he did not know if the previous Director had on-going PI monitoring or not, but he could not find anything. He stated that he did not currently have any QA projects.

2. Record review of the facility plan titled, "Quality Improvement Plan Calendar Year 2012," showed no performance improvement projects for 2012.

Review of the Rehabilitation Department on 02/07/12 at 3:00 PM showed staff did not have any performance improvement projects for the department.

Based on interviews and record reviews the facility failed to ensure an ongoing Quality Assessment/Performance Improvement (QAPI) program was implemented and maintained by the Governing Body, the medical staff and the administrative staff - the leadership of the hospital - by not having a facility wide active QAPI program. This failure of a significant hospital system which will identify problems regarding patient care and services can adversely affect the quality of care for all patients in the facility. The facility census was seven.

Findings included:

Record review of the facility quality plan, titled, "Quality Improvement Plan Calendar Year2012," showed the following:
-Leadership Involvement: Strong leadership, direction and support of quality improvement activities by the hospital board and Chief Executive Officer (CEO) are key to performance improvement. This involvement of organizational leadership assures that quality improvement initiatives are consistent with our mission and/or strategic plan.
-Continuous Quality Improvement Activities: Quality improvement activities emerge from an organized framework for improvement. This framework, adopted by the hospital leadership, is understood, accepted and utilized throughout the organization, as a result of continuous education and involvement of staff at all levels in performance improvement. Quality Improvement involves two primary activities:
-Measuring and assessing the performance of services through the collection and analysis of data.
-Conducting quality improvement initiatives and taking action where indicated, including the design of new services, and/or improvement of existing services.

During an interview on 02/07/12 at 11:15 AM Staff M, Clinic Admissions Manager, and QA (Quality Assurance) for the hospital stated that there were not any performance improvement projects implemented in 2010, 2011, and none for 2012 at this time.

Record review of the facility quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed no performance improvement projects for 2012.

Record review of the facility quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed the Quality Improvement Committee members and the leadership failed to include medical staff as part of the committee.

Record review of the facility quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed the following departments were not included in the hospital-wide plan.
-housekeeping;
-maintenance;
-Out-patient services;
-Emergency Department;
-Discharge Planning.
-Contract services; and
-Swing bed.

Record review of the facility quality plan titled, "Quality Improvement Plan Calendar Year 2012," showed Nursing with only one indicator that dealt with Emergency Department physicians and not any indicators for the Nursing Department.

Based on observation, interview and record review the facility failed to follow their standard of practice for identifying who initiated/changed an intravenous (IV-a needle placed into a vein to supply medication and/or fluids) tubing line for one of two patients (Patient #32) reviewed with IV's. The facility census was six.

Findings included:

1. Review of Patient #32's History and Physical, dated 02/02/12, showed the patient was admitted on that date with diagnoses of dementia, and shortness of breath.

During an interview on 02/08/12, at 9:40 AM, the Director of Nurses, Staff A, stated staff are required to date and initial IV tubing when originally hanged, and when changed. Staff A stated there was no written policy regarding this specific procedure.

Review of IV medication orders dated 02/05/12 - 06/12/12, showed IV medications and/or fluids being administered continuously and intermittently to Patient #32.

Observation on 02/07/12, at 8:54 AM, showed four IV tubing lines being/having been utilized for Patient #32. Three of the IV lines were dated 02/06/12; however, staff failed to initial the IV lines as required.

Based on observation, interview and record review the facility failed to develop a comprehensive, individualized care plan for two (Patients #6 and #7) of four patients reviewed. The facility census was six.

Findings included:

1. Review of a facility policy titled, " Interdisciplinary Plan of Care, " revised 10/07, showed the following:
-Care planning begins at admission;
-The interdisciplinary team identifies patients' care needs and develops a plan to meet those needs, based on the individual assessments;
-The nursing and physician history and physical (H & P), progress notes, orders and medication are also reviewed and utilized in development of the care plan;
-Each problem should have a correlating goal, and identify which discipline is responsible;
-The nurse assigned to the patient is responsible for the development and update of the care plan as necessary.

2. Review of Patient #6's Nursing Admission assessment, dated 02/03/12, showed the patient was admitted to the Swing Bed (a specific program that alters reimbursement based on the skilled treatment required) portion of the facility on that date with a diagnosis of cellulitis (inflammation at the cellular level) of the leg. The patient also suffered from respiratory diseases requiring oxygen, and was extremely hard of hearing requiring hearing aids.

Observation on 02/07/12 at 10:02 AM, showed the patient had oxygen on at 2.5 liters and hearing aids in both ears.

Review of the patient's care plan, dated 02/04/12, showed staff failed to identify the use of the oxygen and the patient's hard of hearing status in the care plan; therefore, neither problem had been addressed with a goal.

3. Review of Patient #7's History and Physical (H& P), dated 02/05/12, showed the patient was admitted on that date with a diagnosis of pain in the right shoulder and lower back (lumbar fracture). The patient was admitted to the Swing Bed portion of the facility for physical therapy and pain management.

Observation and interview on 02/06/12, at 1:17 PM, showed the patient had an indwelling Foley catheter (a tube placed into the bladder to drain urine). There was a container of Ben Gay (a pain relieving ointment) at the patient's bedside, and the patient stated she used it on her legs.

Review of the patient's care plan, dated 02/05/12, showed staff failed to identify the use of the Foley catheter (use of a Foley introduces bacteria and can cause an infection), and the fact that a medication was at the patient's bedside being administered by the patient rather than staff. Therefore, neither problem had been addressed with a goal.

During an interview on 02/07/12 at 11:33 AM, Registered Nurse (RN) Staff P, stated it was possible for the staff to enter the problem of catheter use, with a goal into the care plan; however, the staff failed to do so in this case.

Based on record review and staff interviews, the facility failed to complete three (Patients #5, #6 and #26) of 32 patients' History and Physical (H&P) records reviewed. The facility census was six.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," dated 07/27/09, showed the following:
-A complete admission history and physical examination shall be recorded within 24 hours of admission on all patients admitted to acute care or observation status.
-If a complete history and physical examination has been obtained within a week prior to admission, such as in the office of a physician staff member, a durable, legible copy of this report may be used in the hospital record provided there has been no subsequent change or the changes have been recorded in at the time of admission.

Review of the facility's Rules and Regulations, approved on 01/13/03, showed a complete admission H & P shall be recorded within 24-hours of admission on all patients.

2. Review of Patient #26's medical record showed the patient was admitted to the facility on 01/20/12 through the Emergency Department (ED) with chief complaints of palpitations, heart racing and chest discomfort.

Record review of Patient #26's medical record on 02/09/12 at 2:45 PM showed the physician did not complete a History & Physical (H&P) on the patient.

During interview on 02/09/12 at 3:15 PM, Staff U, Director of Health Information Management (HIM), stated that physicians received a list of records near delinquent status weekly, but they don't always get them done before they become delinquent. Staff U stated that the current Medical Staff Bylaws do not give authority to take actions against physicians who do not get the needed information in the records completed.

3. Review of Patient #5's nursing admission history, dated 02/06/12, showed the patient was admitted, via the emergency department, on that date, at about 10:30 AM, with a complaint of a swollen, red face (right side), a toothache, and a swollen, hard area on the right foot (possible infection).

Review of the patient's medical record on 02/07/12, at 11:04 AM, at 2:00 PM , and at 4:20 PM (all over 24-hours) showed no physician's H& P on the record.

Review of the patient's medical record on 02/08/12, at 10:30 AM (48-hours after admission), showed no physician's H & P on the record.

During an interview on 02/08/12 at 10:30 AM, Unit Clerk, Staff PP called medical records and confirmed there was no H & P dictated for this patient.

4. Review of Patient #6's Nursing Admission History, dated 02/03/12, showed the patient was admitted to the Swing Bed portion of the facility on that date with a diagnosis of cellulitis (inflammation at the cellular level) of the leg.

Review of the patient's medical record on 02/07/12, at 11:20 AM (about 96-hours after admission), showed no physician's H & P on the record.

5. Review of the facility's October, 2011 statistics, regarding H & P completion by physician, showed two of four physicians were delinquent with H & P completion. One of which was delinquent three of five opportunities.

6. Even though requested, several times, the facility failed to provide a policy regarding this process as of 02/08/12 at 9:53 AM.



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Based on record review and staff interviews, the facility failed to complete two (Patient #23 and #24) of four patients' closed medical records reviewed within 30 days of discharge. The facility census was six.

Findings included:

1. Record review of the facility's "Medical Staff Bylaws," dated 07/27/09, showed the following:
-The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient.
-The record shall include a discharge summary or note and autopsy report when applicable.

2. Record review of Patient #23's medical record showed she was discharged from the facility on 07/21/11 with diagnosis of intestines infection due to Clostridium Difficile (C-diff) - bacteria in the intestines.
-Review of the record on 02/09/12 at 3:30 PM showed the facility prepared a discharge summary report on 09/11/11 at 10:29 PM of the patient's admission.
-Record review also showed the facility did not date and sign the report until 10/18/11 at 4:02 PM.

3. Record review of Patient #24's medical record showed he was discharged from the facility on 09/05/11 with diagnoses of liver and lung cancer and lower extremities wounds.
-Record review of Patient's #24's medical record on 02/09/12 at 3:45 PM showed the facility did not prepare a discharge summary report of the patient's admission.
-Record review also showed the record contained a progress noted dated 09/05/11 at 3:13 PM, but the not had not been signed by the person making the entry.

During interview on 02/09/12 at 3:15 PM, Staff U, Director of Health Information Management (HIM), stated that physicians received a list of records near delinquent status weekly, but they don't always get them done before they become delinquent. Staff U stated that the current Medical Staff Bylaws do not give authority to take actions against physicians who do not get the needed information in the records completed.

Based on observation, interview and record review, the facility failed to ensure medications were stored and administered per their policy for one patient (#7) observed with bedside medications. The facility census was six.

Findings Included:

1. Review of a facility policy titled, "Patient's Own Medication and Bedside Medication," reviewed 04/04, showed the following:
-Certain drugs may be left at a patient's bedside for self-administration, upon the order of the physician; These include =
-Topicals such as breast cream, Super Duper Diaper Doo, and Monistat Derm, Nitroglycerin tablets, antacid, eye drops, metered dose inhalers.

2. Review of Patient #7's History and Physical (H& P), dated 02/05/12, showed the patient was admitted on that date with a diagnosis of pain in the right shoulder and lower back (related to a past fracture). The patient was admitted to the Swing Bed (a specific program that alters reimbursement based on the skilled treatment required) portion of the facility for physical therapy and pain management.

Observation and interview on 02/06/12, at 1:17 PM, showed the patient had a container of Ben Gay (a pain relieving ointment) at the bedside, and the patient stated she used it on her legs. There was also a spray can of Granulex (a medication used to treat pressure sores, or to increase circulation to prevent pressure sores) at the patient's bedside. The patient stated it was being used on her heels to prevent pressure sores.

During an interview on 02/07/12, at 3:12 PM, Pharmacist, Staff K, stated medications were not to be kept at the patient's bedside.

Review of the patient's physician's orders from admission through 02/07/12, at 11:53 AM, showed no order for bedside medications. Staff failed to obtain a physician's order, or store and administer the medications per their policy.

Based on observation, interview and policy review the facility failed to ensure undated, open bottles of medication and cleansing agents, and expired medications were not available for patient use in the emergency and out-patient departments. The facility census was six.

1. Record review of the facility policy titled, "Safety: Patients and Personnel," reviewed 04/2004 showed that discontinued or outdated drugs and containers with worn, illegible, or missing labels should be returned to the pharmacy for proper disposition.

Record review of the facility policy titled, "Outdated Medications," reviewed 04/2004 gave the following direction:
-All medications in all areas of the hospital will be checked each month for expiration dates.
-All outdated medications will be separated from active stock.
-Colored round stickers are placed on each medication container that will outdate in the current year. The dot will correspond to the month the medication will outdate.
-The Pharmacist will do random checking in all departments to verify that all outdated medications are being removed.

2. Observation on 02/06/12 at 12:50 PM in Bay #1 of the Emergency Department (ED) showed the following:
-A 16 fluid ounce (oz) (473 ml [milliliters]) bottle of Isopropyl Rubbing Alcohol (A clear flammable fluid used to disinfect the skin.), lot # 31073, expiration date 04/2013, and approximately 400 ml left in the bottle. The bottle was open and no date as to when it was opened.
-A 16 fluid oz (473 ml) bottle of Hydrogen Peroxide (A clear fluid used to disinfect the skin.), lot #31912, expiration date 04/2013, and approximately 250 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-An eight oz (236 ml) bottle of Hibiclens (A type of disinfectant cleanser for the skin.), lot #008156, expiration 01/2013, and approximately 180 ml left in the bottle. The bottle was opened and no date as to when it was opened.

An opened bottle could expire before the manufacture expiration date and a patient could potentially be treated with something expired.

3. Observation on 02/06/12 at 1:00 PM in Bay #3 of the ED showed the following:
-A 5-0 Ethilon (A type of suture), lot #UMB712, expired 07/2010.
-Five of the 3-0 Ethilon, lot #PEP735, expired 01/2005.
-A clear bottle with approximately 240 ml of brown fluid with a hand written label that said Providone Solution (A solution used as a disinfectant for hands and surgical sites.).
- An eight oz (236 ml) bottle of Hibiclens, lot #008156, expiration 01/2013, and approximately 180 ml left in the bottle. The bottle was opened and no date as to when it was opened.
-A 16 fluid oz (473 ml) bottle of Hydrogen Peroxide, lot #29470, expiration date 03/2012, and approximately 250 ml left in the bottle. The bottle was opened and not dated as to when it was opened.

An opened bottle could expire before the manufacture expiration date and a patient could potentially be treated with something expired.

During an interview on 02/06/12 at 1:00 PM Staff D,ED Supervisor, stated that she was aware they were outdated.

4. Observation on 02/06/12 at 1:20 PM in Bay #4 of the ED showed the following:
-A four fluid oz (118 ml) bottle of Children's Acetaminophen oral suspension (A liquid pain reliever.), lot #49259, expiration 07/2012, and approximately 30 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-A four fluid oz bottle of Children's Acetaminophen oral suspension, lot #15260, expiration 08/2013, and approximately 90 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-A four fluid oz bottle of Diphenhydramine (A medication used to treat allergy symptoms of the nasal passages and motion sickness.), lot #OL14, expiration 11/2012, and approximately 100 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-A four fluid oz bottle of Children's Ibuprofen (A liquid pain reliever), lot #L101005, expiration 12/2012, and approximately 100 ml left in the bottle. The bottle was opened and not dated as to when it was opened. An opened bottle could expire before the manufacture expiration date and a patient could potentially be treated with something expired.
-A 480 ml bottle of Prednisolone Oral Solution (A medication that decreases inflammation. [Swelling]), lot # 604704, expiration 03/2012, and approximately 300 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-A 12 fluid oz (355 ml) bottle of Maalox Advanced Regular Strength (A medication to decrease the gas and acid in the stomach.), lot #10109532, expiration 07/2013, and approximately 15 ml left in the bottle. The bottle was opened and not dated as to when it was opened.
-A 16 fluid oz bottle of HYDS Elixir (Donnatal) (A medication to decrease gastrointestinal tract spasms.), lot #13910, expiration 05/2012, and approximately 350 ml left in the bottle. The bottle was opened and not dated as to when it was opened.

An opened bottle could expire before the manufacture expiration date and a patient could potentially be treated with something expired.

During an interview on 02/06/12 at 1:30 PM Staff D, verified that staff did not document the dates the containers were opened.

5. Observation on 02/06/12 at 1:35 PM in Bay #2 of the ED showed the following:
-A 16 fluid oz bottle of Hydrogen Peroxide, lot #31012, expiration 04/2013, and approximately 8 oz left in the bottle. The bottle was opened and not dated as to when it was opened.
-A 16 fluid oz bottle of Isopropyl Rubbing Alcohol, lot #30403, expiration 11/2012, and approximately 15 oz left in the bottle. The bottle was undated and had no expiration date.
-An 8 fluid oz bottle of Hibiclens, lot #00S156, expiration 01/2013, and approximately 150 ml left in the bottle. The bottle was undated and had no expiration date.

An opened bottle could expire before the manufacture expiration date and a patient could potentially be treated with something expired.

During an interview on 02/06/12 at 1:30 PM Staff D, verified that staff did not document the dates the containers were opened.

6. Observation on 02/06/12 at 2:25 PM in the treatment room of the outpatient clinic showed a clear bottle with approximately four ounces of brown fluid with a hand written label that said Providone Solution. The bottle was undated and had no expiration date. Potentially, an expired product could be used for a patient.

During an interview on 02/06/12 at 2:25 PM Staff E, Registered Nurse (RN) stated that the bottle was not dated by the staff.

7. Observation on 02/06/12 at 2:35 PM in the Endoscopy Room (where a colonoscopy, a test using a tube with a camera on the end put into the rectum and into part of the intestine) or EGD, Esophagogastroduodenoscopy-a test using a tube with a camera is put into the mouth and then goes down into the stomach, is done) of a black box in the bottom of the crash cart showed the following:
-A 10 ml vial of Lidocaine HCL (A medication used as a local anesthetic, sedative, and for cardiac arrhythmias), lot #406327, expiration 01/2012.
-A 10 ml vial of Lidocaine HCL, lot #406918, expiration 01/2012.
-A 10 ml vial of Lidocaine HCL, lot #406919, expiration 01/2012.
-Two, 1 ml vials of Depamedrol (A medication that reduces inflammation), lot # DBJP9, expiration 01/2012.
-Two, 1 ml vials of Neosynephrine (A medication used to increase blood pressure), lot # 50160DD, expiration 02/01/2012.
-Two, 16 fluid oz bottles of Isopropyl Rubbing Alcohol, lot #29668, expiration 05/2012, and approximately 14 oz left in one bottle and six oz left in the other bottle. The bottles were undated

8. During an interview on 02/07/12 at 9:15 AM Staff D stated that she was not aware of what the policy for opened bottles of cleansing agents or medication was.

During an interview on 02/07/12 at 9:25 AM Staff J, Certified Surgical Technician(CST), stated that she did checks on outdates last month and two weeks ago and she knew there were some that would be outdating but did not remove them.

During an interview on 02/07/12 at 10:05 AM Staff A, Director of Nursing (DON),
stated that there was not a policy on how to label opened bottles of cleansing agents or medication.

Based on observation, interview and policy review, the facility failed to prescribe all diets in accordance with the current diet manual and the facility failed to have a current approval of the diet manual by the qualified Registered Dietitian (RD) and Medical Staff. The facility census was six.

Findings included:

1. Record review of the facility's Policy titled "Diet Manual and Distribution,"
dated 04/2008 provided by Staff S, the Certified Dietary Manager, CDM, showed the following direction:
-After annual approval of the diet manual by the medical staff, the Consultant Dietitian, Medical Staff Director and the Dietary Manager sign and date the manual.

2. Record review of the Diet Manual showed it did not have an annual approval by the Consulting Dietitian and Medical Staff. The last approval was in 09/2010 by the Consulting Dietitian and CDM.

3. Observation on 02/08/12 at 3:15 PM showed the facility had a hard copy of the current Diet Manual in the Dietary Department and at the nurses' station, but not a copy available for the medical staff.
-Staff S stated that she did not know if the Medical Staff had access to a copy or not.

4. Observation on 02/07/12 at 10:15 AM showed the facility's current Diet Manual's last approval date was 09/2010.
-Observation also showed the physicians ordered diets not found in the approved diet manual; the Medical Staff ordered a "Low Sodium" diet for a patient, which was not a diet terminology in the approved Diet Manual.
-Staff interpreted the order as and served the patient a 4 gram (gm) Sodium (NA) Diet. The interpretation had not been reviewed and approved by the Medical Staff.

5. During an interview on 02/07/12 at 10:22 AM, Staff S stated that she did not have a policy regarding approval of diets served that were not in the Diet Manual.

Based on interview and record review, the facility failed to coordinate with state and local fire authorities and provide written evidence of inspection and approval of the facility's fire evacuation and recovery plan. The facility census was six.

Findings included:

1. During an interview on 02/07/12 at 11:30 AM Staff H, Maintenance Lead said they had not received a visit from a local or state fire authority since he could remember. He said they have not called or written to contact the local fire authority or district Fire Marshal for an annual inspection and review of the facility fire and plans for emergency evacuation of patients.

2. Review of documents on 02/0712 at 11:40 PM showed no information regarding written policy, request for consultation, or documentation of an inspection of the facility by the local fire authority for hazard analysis and review of the facility's emergency evacuation plans for movement and recovery of patients during a fire or similar emergency circumstance.

Based on policy review, record review and interview, the facility failed to ensure cooking facilities were maintained and cleaned on a regular schedule by a properly trained, qualified, and certified company or person to prevent the duct between the kitchen range hood and rooftop exhaust from becoming heavily contaminated with grease or oily sludge. The facility census was six.

Findings included:

1. Record review of the facility's Policy titled "Maintenance and Cleaning Procedure," dated 10/2003 provided by Staff S, the Certified Dietary Manager, CDM, showed the following direction:
Maintenance Department is responsible for the maintenance of the following:
-Stove Hood - Quarterly
-Stove Hood Filters - Monthly
A record of the above maintenance activities is maintained in the Preventive Maintenance Booklet in the Maintenance Department.

2. During an interview on 02/06/12 at 2:10 PM, Staff S stated the following:
-She had not had anyone to clean the vents and ducts of the stainless steel hood over the range within the past two years and she never saw anyone clean it under the previous CDM.
-Maintenance Staff may have cleaned the interior of the hood after hours, but as far as she knew, the interior of the hood had not been cleaned.
-The facility did not have a contract with anyone to clean the hood.

During an interview on 02/07/12 at 3:30 PM Staff I, Housekeeping Supervisor, and Staff H, Maintenance Lead, both stated they had not been tasked to clean the ductwork between the kitchen range hood and the rooftop vent. Staff H stated he was not sure it had ever been cleaned.

3. Sections 11.3 and 11.4 of the Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations (NFPA #96 a federally adopted code from the National Fire Protection Association) specify the parameters and requirements for cleaning, maintenance and inspection of commercial kitchen exhaust hoods by a properly trained, qualified, and certified company or person(s) to prevent flammable grease-laden vapors from accumulating in the smokestack or smoke vent pipe between the kitchen range hood and the terminal exhaust point.





04467

Based on observation, interview, and policy review the facility's staff failed to follow their policy for Contact Isolation (patients identified as having a particular organism especially contagious or difficult to treat) for two patients (#2 & #31) of two current patients on Contact Isolation and the facility failed to conduct surveillance activities of personnel related to hand hygiene and the use of personal protective equipment. Failure to follow contact isolation precautions and failure to conduct surveillance activities could potentially result in cross contamination of infectious organisms and could impact all patients in the facility. The facility census was six.

Findings included:

1. Record review of the facility policy titled, "Contact Precautions," revised 05/14/08, showed the following direction:
-Wear gloves when entering the room and change gloves after contact with infective material that may have a high concentration of microorganisms.
-Wear a gown when entering the room.

2. Observation on 02/08/12 at 1:50 PM showed Staff HH, Registered Nurse (RN) entered Patient #2's room. A sign, posted on the door frame, outside the door read Contact Isolation use a mask, gown and gloves. Staff HH did not have a mask, gown or gloves on. The policy does not state that a mask should be used for Contact Precautions, but the sign posted read a mask, gown and gloves should be used.

During an interview on 02/08/12 at approximately 1:55 PM Staff HH stated that he put gloves on because the patient only had a wound infection.

During an interview on 02/08/12 at 2:45 PM Staff D, Charge Nurse, stated that if touching the patient or bed linen staff should wear a gown. If just talking with the patient or setting a tray down staff should wear gloves and a mask.

Observation on 02/08/12 at 2:47 PM showed Staff J, Certified Surgical Technician, stepped inside Patient #2's door and did not put on a gown or gloves.

During an interview on 02/08/12 at 4:30 PM Staff N, Infection Control Nurse, stated that her expectation for staff is for staff to wear gown and gloves if the patient is on contact isolation.. A mask is added if the microorganism (germ) is airborne.

During an interview on 02/09/12 at 9:40 AM, Patient #2 stated that the previous day the day shift nurse did not ever put on a gown, gloves, or mask when entering her room. The night shift aid and nurse did not wear gowns, masks, or gloves throughout the entire shift.

Record review of Patient #2's History and Physical showed Cellulitis (an infection of the skin) of the right hip/pannus (the overhang of the abdomen).

Review of Patient #2's physician orders showed an order dated 02/08/12 for Methicillin Resistant Staphylococcus Aureus (a bacteria that is resistant to Methicillin, an antibiotic) screening by a culture of the inside of the nose and for cultures of the wound on the right hip/pannus.

3. Observation on 02/09/12 at 4:40 PM showed Staff F, RN stepped from behind the curtain in Patient #31's room. The sign on the door frame outside of the door indicated the patient was on contact isolation precautions and persons entering the room should wear a gown and gloves, but Staff F did not have a gown and gloves on. Observation showed the facility's staff provided gowns and gloves outside of the door on a table for persons to use.

During an interview on 02/09/12 at approximately 4:45 PM, Staff F stated that she did not to wear a gown when she entered Patient #31's room because she only started an IV (Intravenous) line on the patient. When asked about the isolation sign on the door, she stated that she did not anticipate coming in contact with any draining fluids from a wound, therefore, she did not need to wear a gown and gloves.

Review of Patient #31's medical record showed that the patient was admitted to the facility with a diagnosis of cellulitis of the right ankle. On 02/09/12 at 4:17 PM, the physician ordered the patient to be placed in contact isolation due to wound of the right ankle.

4. Record review of the facility's undated job description for the Infection Control Nurse showed, "Specializes in identifying, controlling, and preventing outbreaks of infection in healthcare settings and the community."

Record review of the facility policy titled, "Surveillance, Reporting, and Follow-up of Infections," dated 05/14/2008 showed surveillance activities shall include personnel.

During an interview on 02/07/12 at 2:20 PM Staff N, Infection Control Nurse, stated that there was not any active staff surveillance done by her. (Examples would be staff use of hand hygiene and use of personal protective equipment, follow-up of staff for identification of communicable diseases, staff lab values showing possible infection, and signs and symptoms when staff miss work.)





05760

Based on interview and policy review the facility failed to ensure the Infection Control program maintained an infection control log for the tracking and trending of patient, staff, and volunteer infection data. The facility census was six.

Findings included:

Record review of the facility policy titled, "Surveillance, Reporting, and Follow-up Infections," dated 05/14/08 showed the following:
-Surveillance of patients for infection shall be done to identify baseline information about the frequency and type of endemic infections in order to permit rapid identification of deviations.
-All significant clusters of infection above the expected level shall be investigated.
-Surveillance will be aimed at assessment/observation and early recognition of signs and symptoms of infections, monitoring, analyzing, reporting, and follow-up.

During an interview on 02/08/12 at 2:20 PM Staff N, Infection Control Nurse, stated the following:
-That she did not maintain an infection control log.
-That she failed to track staff or volunteers with communicable diseases that needed to be reported. Communicable diseases identified in patients were not documented in a log to ensure trends could be identified.
-That she failed track staff or volunteers that had laboratory cultures of colonized or infected with multi drug-resistant organisms (MDRO). Patients identified with an MDRO were not documented in a log to ensure accurate trending of data.
-That she failed to track staff or volunteer's symptoms when they called in so she failed to report symptoms that have been requested to be reported or recorded by local, State, or Federal health agencies. The identified symptoms of patient's were not logged to allow for accurate trending of signs and symptoms.
-She failed to track staff and volunteer's that were known to be infected with epidemiologically-significant pathogens (the occurrence, transmission, and control of epidemic, [affecting many people simultaneously in an area] diseases.) Patient's noted with epidemiologically-significant pathogens were not documented in a log to identify a trend in pathogens in patients or spread of the pathogens.

By not keeping track of employee and volunteer signs and symptoms of possible infections, communicable diseases, colonization (the presence of a bacteria, but no signs of illness) or those infected with a MDRO, or those infected with a known epidemiologically-significant pathogens, along with failure to document these identified areas for patients in a log, does not allow for appropriate trending of data. If unable to track and trend data, it is difficult to identify areas that need investigation and performance improvement to prevent spread of infections in the hospital.

Based on interview and record review the facility failed to implement Quality Assurance Performance Improvement (QAPI) to determine whether its discharge planning process effectively identifies patients who need discharge planning and that the plans are adequate and effectively executed. The facility census was six.

Findings included:

1. During an interview on 02/08/12 at 1:55 PM Staff A, Director of Nursing (DON), stated that there is not any QAPI for discharge planning.

2. Record review of the facility plan titled, "Quality Improvement Plan Calendar Year 2012," showed no indicators for discharge planning.

Based on interview and record review the facility failed to integrate out-patient services into the hospital wide Quality Assurance Performance Improvement (QAPI) program. The facility census was six.

Findings included:

1. During an interview on 02/06/12 at 2:25 PM Staff E, Registered Nurse (RN), stated that the out-patient area only does call backs to patients for quality.

During an interview on 02/07/12 at 11:15 AM Staff M, Clinic Admission Manager and QA for the hospital stated that the out-patient department was not integrated into the hospital wide QAPI.

2. Record review of the facility plan titled, "Quality Improvement Plan Calendar Year 2012," showed no indicators for the out-patient department.

Based on interviews and record review, the facility failed to measure, analyze, and track quality indicators on an ongoing basis for the Emergency, Out-Patient, Respiratory, Rehabilitation, Housekeeping, Swing Bed, Discharge Planning and Maintenance Departments. Nursing failed to collect pertinent data to measure and analyze issues related to patient care. These nine departments were unable to identify quality assessment/performance improvement issues and unable to implement any necessary corrective systems. The facility census was six.

Findings included:

1. During an interview on 02/06/12 Staff D Emergency Department (ED) Supervisor stated that the ED was not involved in tracking any Quality Assurance indicators.

During an interview on 02/06/12 at 2:25 PM Staff E, Registered Nurse (RN) who works in the Out-Patient Department stated that the Out-Patient Department was not involved in tracking any Quality Assurance indicator.

During an interview on 02/06/12 at 11:15 AM Staff M, Clinic Admissions Manager and Hospital Quality Assurance stated that the Out-Patient Department did not track any Quality Assurance indicators.

2. Record Review of the facility program titled, "Quality Improvement Plan Calendar Year 2012," showed Emergency, Out-Patient, Respiratory, Housekeeping, Swing Bed, Discharge Planning and Maintenance Departments did not have indicators to track:

Record Review of the facility program titled, "Quality Improvement Plan Calendar Year 2012," showed the following:
-The Rehabilitation (Physical Therapy) Department tracked only one indicator.
-The Nursing Department tracked only one indicator and it was related to the Emergency Department physicians. The Nursing Department failed to track any indicators for the Nursing Department.

3. Review of the Rehabilitation Department on 02/07/12 at 3:00 PM showed staff was not involved in tracking any quality assurance indicators related to high risk problems in the area.

During an interview on 02/07/11 at 3:03 PM, Staff T, Physical Therapy Assistant/Director, stated that he had only been at the facility for one and one half months, but had attended Performance Improvement (PI) meetings. He stated that he did not know if the previous Director had on-going PI monitoring or not, but he could not find anything. He stated that he had a questionnaire that he wanted to pass out to patients regarding patients' satisfaction, but he did not currently have any projects. He stated that he did not have any performance improvement projects because he was told that the program was under construction and he needed to wait until the PI program got "straightened out." When asked how long it would take for things to get straightened out, he said he thought it would be about six months.

Review of the Respiratory Department on 02/08/12 at 3:30 PM showed staff did not collect and analyze data related to high risk problems in the Respiratory Department for the last six months of 2011.

During an interview on 02/08/11 at 3:30 PM, Staff G, Director of Respiratory Therapy and Maintenance Department, stated that he did not collect, analyze and provide data to the hospital-wide Quality Improvement program for the past six months. He stated that he had added duties the past 6 months that did not allow extra time to do any performance improvement projects. He stated that he developed QI monitors for the fiscal year 2012 and presented a copy of his 2012 plan.

During an interview on 02/07/12 at 11:30 AM, Staff G stated Maintenance currently did not have, or participate in a Quality Improvement Program. He stated that they were doing them but quit after "management changes." He stated that QI reports were taken from preventive maintenance rounds and work orders completed by maintenance during the past quarter. He stated that from existing data he found in Maintenance, the last report analysis was done at the end of the first quarter in 2007. He stated there was no other documentation to show that any QI's for maintenance had been developed or implemented since that report.

During an interview on 02/07/12 at 11:50 PM Staff I, Lead Housekeeper stated that the Housekeeping Department failed to implement Quality Assurance indicators to ensure immeasurable improvements of housekeeping processes.

During interviews on 02/07/12 at 2:13 PM, and on 02/08/12, at 3:17 PM, the Director of Nurses, Staff A, stated there were not currently, and had not been, any quality improvement issues tracked for a while (unsure how long, but for at least six months) for the Swing Bed program (a specialized reimbursement category which requires skilled care.) Staff A stated that with budget cuts, she felt they could not meet the minimal regulations. Staff were assigned to many areas of responsibility and it was difficult to do all well. Staff A stated the nurses tackle immediate needs first, and then work on other requirements when time allowed.





04467







29117

Based on record review and interview the facility failed to inform patients of the potential charges on admission, and periodically during the patient's stay for three of three patient's reviewed (#4, #6 and #7). The facility census was six.

Findings Included:

1. During an interview on 02/08/12, at 1:34 PM, the Senior Accountant, Staff U, stated items billed/not billed are not provided to Swing Bed patients. Staff failed to inform patients of potential charges while an inpatient in the Swing Bed program (a specialized reimbursement category which requires skilled care).

During an interview on 02/08/12, at 1:40 PM, the Assistant Director of Nurses, Staff D, confirmed no billing information is provided to the Swing Bed patients.

2. Review of Patients' #4, #6, and #7 records showed no evidence they were provided a list of potential charges while an inpatient.

3. During an interview on 02/08/12, at 1:48 PM, Patient #7 stated she had not been given a list of possible facility charges through this time.

During an interview on 02/08/12, at 2:56 PM, the Director of Nurses, Staff A, stated there was no policy regarding chargeable and non-chargeable items that is followed/presented to patients. Patient's only receive a notice of change in payment/reimbursement status when transferred or admitted to Swing Bed program.

6. Review of a facility-provided list of chargeable items, to all patients, included items such as facial tissues, shampoo-in-a-cap, personal cleansing cloths, baby lotion, disposable bedpans, incontinence wash, incontinence briefs, etc.

Based on observation, interview and record review the facility failed to provide individualized activities, per an assessment, and failed to ensure they had the appropriate, certified staff to provide activities for two of two Swing Bed (a specialized reimbursement category which requires skilled care) patients (#6 and #7). The facility census was six.

Findings Included:

1. Review of a facility policy titled, "Swing Bed Activities Program," revised 06/13/08, showed the following:
-An activity assessment is to be completed by the Activities Coordinator upon patient's arrival;
-The assessment is to include number of outings per week or month, types of activities the patient participated in at home to include reading, arts and crafts, walking, etc;
-There were three classifications of activities-bedside, passive, and active;
-It is the responsibility of the Social Services Director to see that the new arrival is made welcome:
-Documentation shall include-individual patient activity, formulation of the activities calendar.

2. Review of Patient #6's Nursing Admission History showed the patient was admitted to the Swing Bed portion of the facility on 02/03/12 with a diagnosis of cellulitis (inflammation at the cellular level) of the leg. The patient was hard of hearing, with bilateral hearing aids.

Review of the patient's activity assessment, (completed by a Registered Nurse [RN] rather than an Activities Coordinator) dated 02/04/12, showed the patient enjoyed visitors and talking, watched the news on television and got up in a chair. Staff failed to document what the patient's favorite television show was, and other possible interests.

During an interview on 02/06/12, at 3:48 PM, Unit Clerk, Staff PP stated that Activities were assessed, and followed-up on (provided and documented), by the RN assigned to the patient.

Observation on 02/07/12, at 11:20 AM, showed Patient #6 lying in bed (eyes closed). Multiple random observations throughout the survey (02/06-02/09/12) showed no active activities provided by staff.

Review of nurses' notes, from admission through 02/08/12, showed no documented evidence of any activity other than sitting on the edge of the bed talking with staff or watching television. Facility staff failed to provide further documentation that more individualized activities were occurring for Patient #6, even though requested.

Review of the patient's care plan, dated 02/04/12, showed no activity problem, interventions and/or goals.

During an interview on 02/07/12, at 2:13 PM, the Director of Nurses, Staff A, stated the facility currently had no certified Activity Coordinator or Social Services Director. RNs assigned were doing the activity assessments, along with the admission assessment, and providing any activities they can, when they can. Staff A confirmed no staff employed at the facility had the required qualifications to provide an activity assessment and on-going program of activities.

Staff failed to provide an activity calendar, of proposed activities, for the month of February, 2012, even though requested upon entrance to the facility (02/06/12).

3. Review of Patient #7's History and Physical, dated 02/05/12, showed she was admitted to the Swing Bed portion of the facility on that date with a diagnosis of low back pain related to a fracture.

Review of the patient's activity assessment, (completed by a Registered Nurse [RN] rather than an Activities Coordinator) dated 02/06/12, showed the patient enjoyed reading, visitors and talking, and watching news and movies on television. Staff failed to document what the patient's favorite television show was, and other possible interests.

Observation on 02/06/12, at 1:17 PM, showed the patient in a chair in her room. There was no television on, or any other activities being provided.

Observation on 02/07/12, at 10:00 AM, showed the patient in a chair in her room.

Observation and interview on 02/08/12, at 1:48 PM, showed the patient in a chair in her room. Patient #7 stated she did not know what Swing Bed was, and had not attended, or been provided specific activities. Patient #7 stated she typically watched television, sat in her chair and visited with staff/family when they came in.

Review of the patient's care plan, dated 02/05/12, showed no activity problem, interventions and/or goals.

Review of nurses' notes, from admission through 02/08/12, showed no documented evidence of any activity other than sitting in her room, or talking with staff/family. Facility staff failed to provide further documentation that more individualized activities were occurring for Patient #7, even though requested.