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As directed by the Centers for Medicare & Medicaid Services, an unannounced on-site recertification survey was conducted at the facility from 08/24/15 to 08/28/15 focusing on the Conditions of Participation (COPs) in the Medicare Program. The facility was found to be out of compliance with the Condition of Participation of the Governing Body. The severity of this noncompliance created an atmosphere that was ineffective in carrying out the responsibilities for the conduct of the hospital by operating a second line of business within a certified hospital, sharing patient care staff and commingling certified Medicare beds.

Please refer to the CMS 2567 for specific examples.

Based on observations, interviews, open and closed record reviews, and policy and procedure reviews showed:
- The Governing Body allowed the Chief Executive Officer (CEO) to have acute care staff care for both Intermediate Care Residents (ICR, residents in a health related facility designed to provide custodial care for individuals unable to care for themselves because of mental or physical weakness or ailments) and Acute Care Patients (hospital inpatient or swing bed patients).
- The CEO also allowed staff who were not contracted employees or facility employees to perform duties in the Surgical Services suite.
- The CEO failed to have a distinct and independent certified hospital space to care for acute care patients and Swing Bed patients.
The facility census was one.

Record review of the document titled, "Social Security Act," section 1861(e)(1), showed the following definition: (e) The term "hospital means an institution which - (1) Is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons.

During an interview on 08/28/15 at 9:30 AM, Staff NN, Board Chairman stated that:
- He was aware that the Intermediate Care Residents (ICR, alternative to hospital care delivered to elderly people that live in the facility) were being housed on the acute and/or Swing Bed (a specific type of reimbursement for patients that need skilled services, such as therapy, but do not need the level of care of a regular patient bed) inpatient care unit.
- When the facility made the decision to move the ICR from the other end of the facility (the facility used to have a long term care facility at one end) to the acute/swing bed inpatient unit it was because the facility was constantly losing money.
- The belief at the time was to separate the ICR from the acute/swing bed inpatients by placing one group on one side of the hall and the other group on the opposite side.
- The original thought was that eventually the ICR would be phased out and the unit would be only for acute/swing bed inpatients.
- He was aware that staff cared for both ICR and acute/swing bed patients and the staff was shared among both groups of patients.
- He did not know the federal or state regulations but relied on the administrator to know what the regulations were.










18018

Based on interview, record review, and policy review, the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) Committee thoroughly investigated and initiated corrective actions for two severe medication errors. In one case a patient was administered a medication via the wrong route (method of medication administered), which caused cardiac arrest (no pulse, no breathing). The facility failed to investigate the event to determine the cause, and failed to put systemic corrective practices in place to help prevent reoccurrence. In the second case a patient was administered a wrong medication prior to the patient being transferred. This situation was investigated, an action plan was created but the elements of the plan were not implemented or followed up on to ensure patient safety. The facility census was one.

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

Refer to the 2567, under A-0286 for details.








29511

Based on observation, interview, record review and policy review, the facility failed to ensure:
- Medications were administered by the correct route (path by which a medication, drug, fluid, poison, or other substance is taken into the body, such as by mouth, directly into the muscle [IM] or directly into the vein [IV]) for one patient (#13) of two discharged patient records reviewed, which caused a life threatening situation. Patient #13 suffered a cardiac arrest (heart and breathing stopped) because a medication was administered IV but should been given IM. (A405)
- The correct medication was administered in a life threatening situation, for one patient (#42) of two discharged patient records reviewed for medication errors. Patient #42 was administered the wrong medication to dissolve a blood clot while being treated for a heart attack. (A405)
- The facility further failed to investigate why these errors occurred or initiate corrective actions to prevent possible re-occurrence of these errors. This had the potential to affect all patients in the hospital who received medications. The facility census was one.

The severity and cumulative effect of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.23 Condition of Participation: Nursing Services.

The facility was informed on 08/27/15 the situation constituted an Immediate Jeopardy (IJ) for 42 CFR 482.23 CoP: Nursing Services and placed all patients of the facility at risk.

Based on interview, record review and policy review, the facility failed to ensure that patients were screened for discharge risks for one current patient (#1) of one current patient's medical record reviewed, and for three discharged patients (#24, #26 and #27), of three discharged patients' medical records reviewed for a Discharge Risk Assessment (A-0800). The facility also failed to ensure that patients received a Discharge Evaluation for one current patient (#1) of one current patient's medical record reviewed, and two discharge patients (#24, and #26), of three discharged patients' medical records reviewed for a Discharge Evaluation (A-0806). These failures had the potential to lead to the inability to recognize those patients in need of a Discharge Evaluation, which could cause delays in discharge, poor discharge outcomes, and readmission, and could affect all patients. The facility census was one.

The severity and cumulative effects of these systemic failures resulted in the facility being out of compliance with 42 CFR 482.43 Condition of Participation: Discharge Planning.

Based on observation, interview, and record review the facility Chief Executive Officer (CEO), appointed by the Governing Body, failed to ensure three of three staff (J, FF and HH) who provided patient care were employed by the facility or performed services as part of a written contractual agreement. These failures had the potential to allow patient care services to be provided by staff who were not employed or contracted to deliver patient care to all patients admitted for surgical services . An average of ten surgical procedures were performed a month. The facility census was one.

Findings included:

1. Record review of the facility's contracts showed no contract related to the use of staff who were not employees or employed at the facility through a contract.

2. During an interview on 08/25/15 at approximately 7:10 AM, Staff HH, Surgical Scrub Technician (scrub tech), stated that she worked at the facility when needed for specific surgical cases. She further stated that the facility shared staff from the facility [a distinct and separate facility] where she was employed.

3. Observation on 08/25/15 at 8:10 AM through 9:15 AM in the surgical operating room (OR) showed Staff HH performed duties of a scrub tech while a surgical procedure was performed.

4. Observation on 08/25/15 at 7:15 AM through 8:00 AM in the preoperative area (designated room where patient care was performed prior to a surgical procedure) and at 9:30 AM in the post-operative area (designated room where patient care was performed after a surgical procedure), showed Staff J, Registered Nurse (RN) performed patient care duties.

During an interview on 08/25/15 at 9:35 AM, Staff J, stated that she was a shared employee and came from "another facility".

During an interview on 08/26/15 at approximately 9:00 AM, Staff F, Manager of the Surgical Services Department stated that two facilities shared staff. She further stated that Staff FF, RN, was a shared staff member who provided management oversight of the surgical services department when she was not available.

5. Record review of staff personnel records showed no personnel records for Staff J, Staff FF, and Staff HH at the facility.

During a concurrent interview on 08/26/15 at approximately 9:30 AM, Staff Q, Chief Nursing Officer (CNO), and Staff GG, Manager of Human Resources, stated that Staff J, RN, Staff FF, RN, and Staff HH, were not employed at the facility and the facility did not have a personnel record for them. Staff GG, stated staff was shared from another facility that was owned by the facility's management company. She further stated that the Human Resources Department had no contact information on the shared staff. She was not aware of a contract or agreement that applied to the shared staff. Staff Q supported and agreed with Staff GG.

During an interview on 08/28/15 at 10:30 AM, Staff OO, Chief Executive Officer, stated that the facility shared surgical services staff through a management agreement. (The management agreement Staff OO referred to was an agreement with a company for management duties, not a contract with another acute care facility to share any patient care staff). Staff OO stated that the facility did not have a written contract that contained information about employees who worked in the facility and who were not employed by the facility.

Based on interview, record review, and policy review, the facility failed to ensure that Medicare patients' were informed of their discharge rights as described in The Important Message From Medicare (IM) for one current patient (#1) of one current Medicare patient record reviewed and three discharged patients (#24, #26 and #27) of three discharged Medicare patients' medical records reviewed. This had the potential to affect all Medicare patients of failure to be informed of their discharge options and/or exercise their patient rights. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Instructions for New Medicare Hospital Discharge Appeal Rights Letter," dated 03/2009, showed the following directives:
- The intent of this letter [referring to the Important Letter From Medicare] is to provide patients with information regarding their rights to appeal a physician's discharge order, but even more importantly, for the patient and family to become more involved and included in discharge planning.
- The letter is presented within two days after admission to each patient who is a Medicare beneficiary (this includes Medicare Replacement Beneficiaries) and admitted to an acute level of care.
- Two days prior to discharge, the copy of the letter from the chart should be presented to the patient again, and he or she should initial or sign on the bottom of the second page. It should be copied and placed on the chart and the patient given the copy with the original initials/signature on the second page.
- Utilization Review staff will be responsible for IM letter distribution Monday through Friday, 7:00 AM to 3:00 PM, with forms made available to nurses in the nurses' station, available in the Social Services and Utilization Review offices, and on the computer where it can be printed off.

2. During an interview on 08/24/15 at 3:00 PM, current Patient #1 stated that he did not receive the Important Message From Medicare upon admission to the facility.

Record review of Patient #1's medical record showed the patient was receiving Medicare and was admitted to the facility on 08/07/15 as an acute care patient.

During an interview on 08/25/15 at 11:30 AM, Staff N, Medical Records, stated that there was no IM for Patient #1.

3. Record review of discharged Patient #24's medical record, who was admitted on 06/21/15, and discharged on 06/24/15, showed there was no IM provided on admission or discharge.

4. Record review of discharged Patient #26's medical record, who was admitted on 06/24/15, and discharged on 06/29/15, showed there was no IM provided on admission or discharge.

5. Record review of discharged Patient #27's medical record, who was admitted on 07/02/15, and discharged on 07/04/15, showed there was no IM provided on admission.

During an interview on 08/25/15 at 9:15 AM, Staff AA, Manager of the Medical-Surgical (Med-Surg) Department, verified there were no IMs in Patient #24, #26 and #27's medical records. Staff AA stated that it was the responsibility of nursing staff or Staff BB, Patient Navigator, to ensure that patients received the IM upon admission, and again before they were discharged.

During an interview on 08/25/15 at 1:15 PM, Staff BB, verified there were no IMs in Patient #24, #26 and #27's medical records. Staff BB stated that it was the responsibility of nursing staff to ensure that patients received the IM.

During an interview on 08/27/15 at 9:10 AM, Staff LL, Registered Nurse (RN), stated that it was the responsibility of Staff BB, or Social Services staff to ensure that patient's received their IM.

During an interview on 08/26/15 at 9:50 AM, Staff CC, Director of Medical Records, stated that no IM's were given to any private pay patients because Medicare didn't pay for their care so they didn't have to be given the IM.






29047

Based on interview, record review, and policy review the facility failed to ensure that inpatients or their representatives were informed of the state agency contact information to file a complaint or grievance about the medical care they received for one patient (#1) of one patient medical record reviewed. This had the potential to prevent all past, present and future patients or their representatives from filing a formal complaint to the state regulatory office regarding their care. The facility census was one.

Findings included:

1. Record review of facility policies showed no policy on Patients' Rights for their acute care inpatients.

2. Record review of the inpatient admission packet showed that the Patients' Rights did not contain information on the facility's complaint procedure(s). The admission packet did contain a separate piece of paper titled, "Complaint Procedure" with the following information:
- Ask to speak to the unit supervisor/manager. Tell unit supervisor/manager your grievance.
- You may also write us a letter. Our address is . . .
- GRIEVANCE PROGRAM: In the event you are not satisfied with our response to your grievance, you may request a review be initiated. Contact the Director of Patient Services for specific information on how to submit a grievance.
- Also, enclosed is a list of other agencies and phone numbers for additional assistance.
The document did not contain the name, address or telephone number of the State Agency as required in any of the documents.

During an interview on 08/25/15 at 2:15 PM, Staff Q, Chief Nursing Officer (CNO), stated that he was not aware that the complaint procedures with the State Agency contact information was required to be in the Patients' Rights information given to the patients.

Based on interview, record review, and policy review, the facility failed to ensure that:
- The Quality Assessment/Performance Improvement (QAPI) Program showed evidence of collaboration with Pharmacy including the Pharmacy Therapeutics Committee in order to identify and track medication errors and adverse drug reactions for two (#13 and #42) of two discharged patients reviewed that experienced medications errors.
- The facility also failed to follow their policy when they did not conduct a Root Cause Analysis (RCA-a method of problem solving used for identifying the root cause of faults/problems) for one (#13) of one discharged patient reviewed that experienced an adverse drug reaction after being administered the wrong medication and dose.
These failed practices to ensure staff utilized safe medication administration had the potential to adversely affect all patients in the facility that received medications. The facility census was one.

Findings included:

1. Record review of the facility's policy titled,"High Risk/High Alert Medications," dated 01/2006, showed that cardiovascular/resuscitation agents (medications that stimulate or depress heart functions) were deemed to be a High Risk /High Alert medication. As such the medication will be stored in a red bin, verbal orders will follow strict, "fail safe," components that require the prescriber to repeat the name, dose, and route of the medication, and the pharmacy will utilize,"TALL MAN LETTERING," within the Omnicell (automatic medication dispensing cabinet) and the drug will note the need for caution.

Record review of the facility's policy titled, "Adverse Drug Reaction Reporting," dated 05/2013, showed:
- A "Severe" adverse event would be defined as life threatening;
- Completed reports (investigation) will be forwarded to the Pharmacy and Therapeutics (P&T) Committee to be reviewed;
- The purpose for being reviewed would be to:
- Educate healthcare professionals on drug effects and increase their level of awareness with regard to adverse drug reactions;
- Institute corrective actions designed to improve patient outcomes by minimizing potential adverse drug reactions;
- Provide quality improvement findings for use in drug evaluation programs.

2. Record review the facility's document titled, "Risk Management Plan," dated 01/2015, showed that:
- Objectives of the plan were to identify factors and minimize the occurrence of situations that present a risk of injury to patients;
- Utilize event reports and performance improvement activities as data resources;
- Investigate all pertinent facts about the situation;
- Conduct hospital wide review of incidents and injuries to patients;
- Design programs to reduce risk in the clinical aspects of patient care and safety.

3. Record review of facility's documents titled, "Adverse Drug Reaction Report," and "Event Report" both dated 06/28/15 signed by Staff EE, Registered Nurse (RN), and Staff Z, RN, showed that Patient #13 was mistakenly administered 0.3 milligrams (mg- a unit of measure) of epinephrine (a medication used in allergic reactions that is also a heart stimulant depending on route of administration and strength),1:1000 (concentration) via intravenous (IV- needle placed into a vein used to administer fluids and medications), route rather than by subcutaneous (sub-q, administer under the top layer of skin) injection. Almost immediately after the injection Patient #13 had a witnessed cardiac arrest (no heartbeat, no breathing), was shocked (electrical shock to the heart via paddles) and eventually returned to baseline (normal for the patient).

4. Record review of Patient #13's medical record showed that on 06/28/15 at 11:56 AM, the patient came to the Emergency Department (ED) and complained of "multiple bee stings" and a red rash over her body.

Record review of the Medication Administration Record (MAR) for Patient #13 showed that on 06/28/15 at 12:00 PM, Staff Z administered by IV, 0.3 mg of epinephrine, 1:100 concentration. The MAR indicated that the medication was to be administered intramuscularly (IM).

During a telephone interview on 08/27/15 at 2:00 PM, Staff UU, ED physician, who treated patient) stated that due to the patient's condition, she gave Staff EE and Staff Z a verbal order for several medications that included 0.3 mg of epinephrine. Staff UU stated that she wasn't sure of the concentration ordered but it was 1:10,000 or 1:1,000, by IM injection, "like the epi-pen," (a pre mixed dose of epinephrine used by individuals known to have severe allergic reactions to bee stings and other elements). Staff UU stated that the Nurse (Staff EE, RN) who took the order knew what she wanted because there was a patient earlier that day with the same symptoms. Staff UU stated she had not discussed this event with Staff EE or Staff Z. Staff UU stated that she had not been contacted by anyone at the hospital about what happened.

During a telephone interview on 08/27/15 at 10:20 AM, Staff EE, stated that, based on the patient's condition, she asked Staff UU if she, the doctor, wanted several medications that included 0.3 mg of epinephrine and Staff UU said, "yes." Staff EE stated that there was no repeat back but she knew what medications, dose, and routes were used for allergic reactions. Staff EE stated that she entered the orders for the doctor, pulled the medications from the Omnicell (medication dispensing cabinet) and left them in the medication room for Staff Z. Staff EE stated that she heard the cardiac arrest initiated and responded to Patient #13's room. Staff EE stated that later that afternoon she was asked by Staff X, ED Manager, to print some medication information from the Internet about epinephrine and provide it to Staff Z for review. Staff EE stated that, in retrospect, this was a serious event and believed that it should have been investigated more thoroughly and used as an educational opportunity.

During an interview on 08/27/15 at 8:40 AM, Staff Z, ED RN, stated that she obtained the medication that had been pulled for her by Staff EE from the medication room. Staff Z stated that Staff UU told her to give the epinephrine IV. Staff Z stated that she confirmed with the physician that she wanted the medicine to be given IV and the doctor stated,"Yes". Staff Z stated that moments after the epinephrine was given IV, Patient #13 went into cardiac arrest. Patient #13 was successfully resuscitated via electrical shock to the heart. Staff Z stated that the vial of epinephrine did not have any warning stickers attached, and the ED nurses regularly took verbal orders from ED physicians. Staff Z stated that except for Staff EE and Staff X, she had not discussed this event with anyone else at the facility.

During a telephone interview on 08/26/15 at 2:45 PM, Staff X, ED Manager, stated that Staff Z had been thoroughly educated on epinephrine after the event. Staff X stated that he had not spoken with Staff UU or Staff EE about Patient #13's care. Staff X stated that he was not sure if epinephrine had "TALL MAN LETTERING" in the OMNICELL or if the vial had warning stickers attached but he did not think so. Staff X stated that he asked Staff EE to get some medication information off the Internet and review it with Staff Z. Staff X stated that he met with Staff Z and advised her to know the medications, and if she wasn't sure to look it up. Staff X stated he advised Staff Z to be careful about the route medications are supposed to be administered. Staff X stated that no additional education was provided to staff.

During a telephone interview on 08/27/15 at 10:45 AM, Staff O, RPh (Registered Pharmacist- Director of Pharmacy) stated that he did not believe that the Omnicell reflected "TALL MAN LETTERING" for epinephrine or if the vial had any warning sticker attached, he would need to check the policy to see if that applied. Staff O stated that he believed this error was a failure of the nurse. Since then, she had been educated, and there was nothing the pharmacy could have done to have prevented this error. Staff O stated that he believed the event was investigated by the hospital. He stated the Pharmacy &Therapeutics (P&T) Committee had discussed the occurrence but did not request any further action. The P&T committee did not request to speak to the physician. Staff O stated that initially he believed that education of the RN addressed the issue but in retrospect there should have been a thorough investigation to determine what caused this error and what could be implemented to prevent this type of error in the future.

During an interview on 08/26/15 at 10:15 AM, Staff Q, RN, Chief Nursing Officer (CNO), stated that Staff Z was reeducated on the medication. He stated that there was no additional education or investigation done but the process should have been more robust and included a RCA. Staff Q stated he left the investigation and education up to Staff X. Staff Q stated that the event was discussed at the Medication Safety Committee, and the P&T committee but no areas for improvement were identified.

During an interview on 08/26/15 at 11:00 AM, Staff II, RN, Director of Quality, stated that a complete investigation of this event should have been done but wasn't. Staff II stated that she was on vacation when the incident happened; when she returned she asked Staff Q about it and was told that he and Staff X took care of it, so she did nothing further.

During an interview on 08/27/15 at 1:00 PM, Staff II, RN, Director of Quality, stated that:
- The facility did not have a current policy and procedure related to Root Cause Analysis (RCA) or Sentinel Events (an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof).
- A RCA was not done for the Epinephrine (medication used to treat life-threatening allergic reactions caused by insect bites or stings) incident because she was on vacation when the incident occurred.
- Staff Q informed her that extensive education had taken place with the nurse that administered the medication, the incident was discussed in the patient safety meeting and determined no other action was needed related to the event.
- A Sentinel Event was anything that caused harm or potential to cause serious harm.
- She considered the Epinephrine incident a serious event.
- She felt like everything Staff Q had done covered the investigation and he was still working on the interview with the ED physician.

5. Record review of the facility's document titled, "Pharmacy and Therapeutics Committee Meeting Minutes," dated 07/28/15 showed the adverse drug reaction related to epinephrine was reviewed and marked, "No further action taken."

6. Record review of the facility's documents titled, Emergency Department Staff Meeting Minutes" dated 06/2015 (no specific date) and 07/27/15 showed no specific discussion or education related to epinephrine or medication safety.

7. Record review of Patient #42's discharged Emergency Department (ED) record showed she presented to the facility on 03/07/15 at 11:04 AM with complaints of change in level of conscience and slurred speech.

Record review of the patient's ED Physician Documentation dated 03/07/15 showed he ordered Alteplase (also known as Activase-medication used to dissolve blood clots related to heart attacks, stroke, chest pain and blood clots in the lungs) 0.9 milligrams (mg) per kilograms (kg). "The patient will be transferred to the accepting facility as a code stroke (a person that has suffered a stroke").

Record review of the patient's ED Order Summary dated 03/07/15 showed an order for Activase 86 mg to be administered with Normal Saline (NS-a sterile mixture of salt and water that is similar to the body's fluids) 50 mg IV (intravenous-needle placed into a vein used to administer fluids and medications) times one now.

Record review of the patient's ED Notes dated 03/07/15 showed ED nursing staff documented that:
-The patient was prescribed a total of 86 mg of TNKase (medication used to treat acute heart attacks by dissolving unwanted blood clots) to be administered.
-The facility had 50 mg of TNKase on hand and the patient received 8.6 mg given over one minute as a bolus (a dose of medication administered all at once).
-The other 4.1 mg was added to 1000 milliliters (ml) bag of NS to be infused over 30 minutes.
-The receiving facility was informed that the patient would need an additional 36 mg of TNKase when she arrived at their facility.
The ED physician ordered Activase not TNKase to be administered and staff failed to administer the correct medication and dosage to the patient.

Record review of the patient's ED Notes dated 03/08/15 showed the ED physician documented the following addendum:
-After the patient was transferred to the receiving facility he was notified that the patient had been given TNKase and not Alteplase.
-It was presumed the patient had received Alteplase which was the medication ordered.
-The maximum dose of TNKase is 50 mg which was what the patient received.
-ED nursing staff reported to the receiving facility that the patient was administered TNKase 50 mg.

During an interview on 08/27/15 at 1:00 PM, Staff II, Registered Nurse (RN), Director of Quality, stated that:
- A RCA was done for the incident when TNKase was administered instead of the ordered Alteplase and as a result an action plan was identified that the facility needed to develop a process called "time out" (a process to confirm a procedure or medication before conducted or administered) in critical situations with the provider present. This needed to be done whenever clarification of high risk (medications/procedures that bear heightened risk of causing significant harm when they are used in error) care is being performed.
- She did not follow-up to ensure the policy/procedure and education had taken place for the incident where TNKase was administered to the patient instead of the Activase that the physician ordered..
- As of 08/28/15 she had not received the "time out" policy/procedure, staff education or any reports related to the TNKase incident.
- She did not know if Staff X followed-up with the patient.

During an interview on 08/27/15 at 3:00 PM, Staff X, RN, ED Manager, stated that:
- TNKase is no longer available in the ED.
- At the June ED staff meeting he reminded staff to practice the five rights of medication administration (right patient, right drug, right dose, right route and right time).
- He has not educated ED staff about "time out" before high risk procedures in ED as of 08/27/15.
- He has not written a policy/procedure for "time out" before high risk procedures for the ED as of 08/27/15.
- He and Staff Q were responsible for staff education, policy/procedure and report findings to the Director of Quality Management.

During an interview on 08/27/15 at 5:15 PM, Staff Z, ED RN, stated that she did not perform a "time out" before she administered TNKase to Patient #42.

These two severe medication errors and the facilities failure to investigate one error, and failure to implement the action plan created as a result of the second error, showed a failure to utilize a multidisciplinary approach between the QAPI program and Pharmacy to ensure patient and medication safety in the facility.











29511

Based on observation, interview, record review and policy review, the facility failed to ensure that medications were administered by the correct route (mouth, intramuscular- IM [directly into the muscle], intravenous- IV [directly into the vein], subcutaneous- sub-q [into the outer surface of the skin], or that the correct medication was given to a patient in a life threatening situation, for two patients (#13 and #42) of two discharged patient records reviewed for medication errors. This had the potential to affect all patients in the hospital who received medications. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "High Risk/High Alert Medications," dated 01/06 showed that cardiovascular/resuscitation agents (medications that stimulate or depress heart functions) were deemed to be a High Risk /High Alert medication. As such the medication will be stored in a red bin, verbal orders will follow strict, "fail safe," components that require the prescriber repeat the name, dose, and route of the medication, and the pharmacy will utilize, "TALL MAN LETTERING," within the Omnicell (automatic medication dispensing cabinet) and the drug will note the need for caution."

2. Record review of discharged Patient #13's medical record showed that on 06/28/15 at 11:56 AM, the patient came to the Emergency Department (ED) complaining of "multiple bee stings" and a red rash over her body.

Record review of the Medication Administration Record (MAR) for Patient #13 showed that on 06/28/15 at 12:00 PM, Staff Z, RN (Registered Nurse), administered 0.3 milligrams (mg.- a unit of measure) of epinephrine (a medication used in allergic reactions that is also a heart stimulant depending on route of administration and strength), 1:100 concentration, IV. The MAR indicated that the order was to be administered sub-q.

During a telephone interview on 08/27/15 at 2:00 PM Staff UU, ED physician, stated that because of the patient's rash she gave a verbal order for several medications that included 0.3 mg of epinephrine. Staff UU stated that she wasn't sure of the concentration ordered but it was 1:10,000 or 1:1,000, by IM injection, "like the epi-pen," (a pre mixed dose of epinephrine used by individuals known to have severe allergic reactions to bee stings and other elements. Staff UU stated that the Registered Nurse (RN) who took the order knew what she wanted because there was a patient earlier that day with the same symptoms.

During a telephone interview on 08/27/15 at 10:20 AM, Staff EE, RN, stated that she asked Staff UU if she, the doctor, wanted several medications that included 0.3 mg of epinephrine and Staff UU said, "yes" Staff EE stated that there was no read back but she knew what medications, dose, and routes were used for allergic reactions. Staff EE stated that she entered the orders for the doctor, pulled the medications from the Omnicell and left them in the medication room for Staff Z, RN.

During an interview on 08/27/15 at 8:40 AM, Staff Z, RN, stated that she obtained the medication that was left for her in the medication room. Staff Z drew up the epinephrine and was about to change the access needle on the syringe of epinephrine when Staff UU told her to give it IV. (The syringe would connect to a port on the IV tubing without a needle). Staff Z stated that she confirmed with the physician that she wanted the medicine to be given IV and the doctor stated, "Yes". Staff Z stated that moments after the epinephrine was given IV, Patient #13 went into cardiac arrest (no heartbeat or breathing). Patient #13 was successfully resuscitated via defibrillation, (electrical shock to the heart). Staff Z stated that there was no "TALL MAN LETTERING" on epinephrine in the Omnicell, no special color bin for this medication, the vial did not have any warning stickers attached, and the ED nurses regularly took verbal orders from ED physicians.

During a telephone interview on 08/26/15 at 2:45 PM, Staff X, ED Manager, stated that Staff Z had been thoroughly educated on epinephrine after the event. Staff X stated that he had not spoken with Staff UU or Staff EE about Patient #13's care. Staff X stated that he was not sure if epinephrine had "TALL MAN LETTERING" in the OMNICELL or if the vial had warning stickers attached but he did not think so.

During a telephone interview on 08/27/15 at 10:45 AM, Staff O, RPh (Registered Pharmacist- Director of Pharmacy) stated that he did not believe that the Omnicell reflected "TALL MAN LETTERING" for epinephrine or that the vial had any warning sticker attached, he would need to check the policy to see if that applied. Staff O stated that he believed this was a failure of the RN, and there was nothing the pharmacy could have done to have prevented this.

3. Observation on 08/27/15 at 1:10 PM showed a vial of epinephrine, 1:1000,1 mg, pulled from the ED Omnicell had no warning sticker attached. The label of the vial stated, "For IM or Sub-q use only."

4. Record review of Patient #42's discharged Emergency Department (ED) record showed she presented to the facility on 03/07/15 at 11:04 AM with complaints of change in level of conscience and slurred speech.

Record review of the patient's ED Physician Documentation dated 03/07/15 showed he ordered Alteplase (Activase-medication used to dissolve blood clots related to heart attacks, stroke, chest pain and blood clots in the lungs) 0.9 milligrams (mg) per kilograms (kg). The patient will be transferred to the accepting facility as a code stroke.

Record review of the patient's ED Order Summary dated 03/07/15 showed an order for Activase 86 mg to be administered with Normal Saline (NS-a sterile mixture of salt and water that is similar to the body's fluids) 50 mg IV (intravenous-needle placed into a vein used to administer fluids and medications) times one now.

Record review of the patient's ED Notes dated 03/07/15 showed ED nursing staff documented that:
-The patient was prescribed a total of 86 mg of TNKase (medication used to treat acute heart attacks by dissolving unwanted blood clots) to be administered.
-The facility had 50 mg of TNKase on hand and the patient received 8.6 mg given over one minute as a bolus (a dose of medication administered all at once).
-The other 4.1 mg was added to 1000 milliliters (ml) bag if NS to be infused over 30 minutes.
-The receiving facility was informed that the patient would need an additional 36 mg of TNKase when she arrived at their facility.

Record review of the patient's ED Notes dated 03/08/15 showed the ED physician documented the following addendum:
-After the patient was transferred to the receiving facility he was notified that the patient had been given TNKase and not Alteplase.
-It was presumed the patient had received Alteplase which was the medication ordered.
-The maximum dose of TNKase is 50 mg which was what the patient received.
-ED nursing staff reported to the receiving facility that the patient was administered TNKase 50 mg.

During an interview on 08/27/15 at 3:00 PM, Staff X, RN, ED Manager, stated that:
-TNKase is no longer available in the ED.
-At the June ED staff meeting he reminded staff to practice the five rights of medication administration (right patient, right drug, right dose, right route and right time).
-He has not educated ED staff about "time out" before high risk procedures in ED.
- He has not written a policy/procedure for "time out" before high risk procedures for the ED as of 08/27/15.

During an interview on 08/27/15 at 5:15 PM, Staff Z, ED RN, stated that she did not perform a "time out" before she administered TNKase to Patient #42.



18018

Based on observation, interview, and policy review, the facility failed to ensure the security of medications in four out of four crash carts (a cart that contained lifesaving medications used in emergencies) and one of three mobile treatment carts (wheeled cart that contained medications) located in the outpatient treatment area. This had the potential to allow unauthorized persons to access medications in the carts. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Emergency Crash Carts" revised 03/2014, showed that after an emergency, nursing will restock all items, when restocking has been completed; they will seal the cart with a red break-away numbered lock tag (red tag).

Record review of the facility's policy titled, "Medication Security", dated 02/01/2010, showed the following direction:
- All drugs were kept secured and only assessable to authorized persons.
- Unattended medication carts were locked when not in use.
- Pharmacy staff were assigned to maintain security of mobile drug carts.

2. Observation on 08/25/15 at 2:10 PM showed a small brown cardboard container sat on top of the pediatric crash cart located in the trauma room of the emergency department with 16 red tags. The small brown cardboard container was left in the open and unsecured. That allowed unauthorized access to the various emergency medications, supplies and equipment inside the crash cart. The cart could then be relocked without anyone's knowledge.

During an interview on 08/25/15 at 2:10 PM, Staff Y, Registered Nurse (RN), House Supervisor, stated that the 16 red tags in the opened small brown cardboard container were not secured and available for access to unauthorized persons.

3. Observation on 08/26/15 at 8:25 AM showed Staff AA, Manager of Medical/Surgical (Med Surg), at the crash cart located in front of the nurses' station. The crash cart was secured with a red tag. She stated that if the crash cart needed to be opened that the blue plastic break-away numbered locking tag (blue tag) from pharmacy was discarded and the nurse would lock the crash cart with a red tag. She showed where the extra red tags were stored in the 2nd drawer behind the unsecured nurses' station. The drawer was unlocked and contained approximately 15 red tags with random numbers. She stated that the crash cart is checked daily and that the crash cart log kept track of the plastic locking tags. Observation of the crash cart log showed the following:
- 08/13/15 red tag numbered 7015015;
- 08/14/15 red tag numbered 7015614;
- 08/16/15 red tag numbered 021922; and
- 08/17/15 red tag numbered 021975.
This series of dates and red tag numbers validated that there was no control over the series of numbers or the number of red tag used to secure the crash cart that stored emergency medications and supplies. This failure would allow any facility staff or visitors unauthorized access to open the crash cart, remove items, and then attach another red tag to appear the crash cart was secured and ready for emergency events. Staff AA stated that the nurses do not have a procedure to contact the pharmacy when something is removed because the Pharmacy Technician (Tech) checked the crash carts every day.

4. Observation on 08/26/15 at 1:10 PM showed the Operating Room/Post Anesthesia Care Unit crash cart was locked with a red tag.

During interview on 08/26/15 at 1:10 PM, Staff F, RN, Manager of Surgical Services stated that she kept one red tag hidden on top of the crash cart. Staff F stated that she could not locate the red plastic tag that she normally had hidden in a blue colored container on top of the crash cart.

5. Observation on 08/27/15 at 8:30 AM showed Staff F, Manager of Surgical Services, at the crash cart located in the Outpatient/Rehabilitation Unit. The crash cart was secured with a red tag . Staff F showed where the extra red tags were stored on top of the crash cart under some gauze in an effort to conceal the tag. She stated that the nurses checked the emergency supplies on the cart and that pharmacy checked the emergency medications.

During a telephone interview on 08/27/15 at 10:20 AM, Staff O, Registered Pharmacist (RPh), Director of Pharmacy, stated that:
- The Pharmacy Tech checked the crash carts daily and if there is a red tag on the crash cart would check the emergency medical contents, replace any items used, and secure the crash cart with a blue tag from the pharmacy.
- He stated that he was unaware that the red tags were not secured and were not used in a numbered sequence.
- His expectation was that the red tags were secured and that the pharmacy was informed any time the crash carts were used.

6. Observation on 08/27/15 at 2:05 PM showed the crash cart in front of the nurses' station on the Med/Surg floor was still secured with the red tag numbered 021975 that was logged on 08/17/15 which indicated that the Pharmacy Tech had not checked the contents and replaced the red tag with a blue tag.

7. During an observation and concurrent interview in the Outpatient care area on 08/27/15 at 9:40 AM, showed:
- More than five patients waited for treatment in the hallway approximately 10 feet from the Podiatry treatment room.
- One large plastic container that contained 154 unsecured medications on the mobile treatment cart in the Podiatry treatment room.
- Medications found unsecured were injectable antibiotics (used for the treatment of infection), injectable pain medications, and medication to stop bleeding.
- Staff G, RN, stated that the cart that contained the medication box was not in use; no Podiatry patients were scheduled and the medications should have been secured.



27029





17863

Based on interviews and record reviews, the facility failed to ensure the Manager of Dietary Services was qualified by experience or training as required by the Missouri State Hospital Regulations and the facility's job description. This had the potential to affect all patients, visitors and staff that utilized the facility's dietary services. The facility census was one.

Findings included:

1. Record review of the Missouri State Hospital Regulations at 19 CSR 30-20.090(1) showed that the Director of Dietary Services is qualified by education, training and experience in food service management and nutrition through an approved course for certification by the Dietary Managers Association or registration by the Commission on Dietetic Registration of the American Dietetic Association, or an associate degree in dietetics of food systems management.

2. Record review of the personnel file for Staff S, Dietary Manager (DM), job description titled, "Manager, Dietary Department," dated 03/2008, showed the following information:
- Special training in food services gained through adequate food service experience or special courses in hospital food service and nutrition.
- Current membership in a professional dietetics organization is also required.
- A bachelor's degree in Food Services Management, Health Services Management or a related area is preferred.
- Further review showed he had a certificate from a culinary school but did not have evidence that he had completed the required certified dietary manager course or obtained his Certified Dietary Manager (CDM) certification.

During an interview on 08/26/15 at 2:15 PM, Staff KK, Registered Dietician (RD) stated that Staff S did not perform any clinical functions because he did not have his CDM certification.

During an interview on 08/27/15 at 2:15 PM, Staff S, DM, stated that he did not have his CDM to date.

Based on observation, interview and policy review, the facility failed to ensure staff removed outdated/expired supplies and equipment from the Emergency Department (ED) and ED crash cart (a cart that contained lifesaving medications used in emergencies). The failed practice to keep outdated/expired medications and equipment out of patient care areas had the potential to pose a health risk to all patients seeking care and services in the facility's ED. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Policy and Procedure for Outdated Supplies," revised 03/2014 showed the following directives:
- In order to prevent outdating, all supplies must be rotated on the shelves and on the carts.
- Each department is responsible for keeping their supplies updated.
- All outdated supplies are returned to Central Supply.

2. Observation on 08/25/15 at 2:10 PM showed the following outdated supplies/equipment in the facility's ED trauma room and crash cart:
- Endotracheal tubes (ET-a tube that is inserted through the mouth down into the trachea [windpipe] used to establish and maintain an open airway to assist with breathing):
- Three 2.5 sized ET tubes that expired on 09/2014;
- Two 3.0 sized ET tubes that expired on 12/2014; and
- One 10 size ET tube that expired 08/2014.
- Two Shiley trach cannulas (Shiley- size of the inner trach cannula) one size 6.4 that expired on 05/2015 and one size 7.6 that expired on 06/2015.
- Five Providone Iodine swab sticks (first aid antiseptic used to help prevent skin infections) that expired on 06/2015.
- One Cook Chest drain valve (used to treat tension pneumothorax - a life-threatening condition caused from chest trauma) with expired date of 06/2015.

During an interview on 08/25/15 at 1:45 PM, Staff Y, Registered Nurse (RN), House Supervisor, stated that ED nursing staff was to check monthly for outdated/expired equipment or supplies. Staff Y stated that she expected staff to remove outdated/expired equipment and supplies from patient care areas in the ED.

Based on observation, interview, and record review, the facility failed to:
- Ensure staff properly cleansed the food prep table surface in the kitchen after spills of various liquids.
- Ensure that kitchen staff practiced hand hygiene after glove removal.
- Maintain a sanitary environment for the preparation of food in the facility's kitchen that is responsible for preparation and service of three meals daily, including cafeteria service and room tray service in a 70 bed hospital. Poor food sanitation potentially affects the health of patients, staff, and visitors and could be a significant and deadly factor for patients recovering from surgery or illness. The facility census was one.

Findings include:

1. Record review of the US Department of Health and Human Services, Public Health Service, Food and Drug Administration, 2013 Food Code showed equipment used in the preparation of food should be free of accumulated dust, dirt, food residue and other debris in accordance with Chapter 4-601.11 (AC), and cleaned frequently to remove accumulated soil residues in accordance with Chapter 4-602.13. Floors shall be of smooth and easily cleanable material in accordance with Chapter 6-201.11 and uniforms, including hair covers in accordance with Chapter 2-304.

2. Record review of the facility's policy titled, "Prep Table Sanitation," dated 08/2015, showed the directive for kitchen staff to clean and remove debris from surface once preparation of a food item is complete. Sanitize surface using proper solution and let air dry a minimum of 60 seconds until the surface is dry.

3. Observation on 08/25/15 at 10:15 AM showed Staff VV, Dietary Aid, wiped down the prep table surface with a dry towel after liquid from various foods had spilled onto the surface.

During an interview on 08/25/15 at 10:45 AM, Staff VV, stated that:
- She was supposed to use sanitizer/disinfectant solution to wipe off the prep table surface after she had prepped food and especially after she worked with meat.
- She tried to wipe up spills after they happened and she changed the sanitized/disinfectant solution when it became "yucky", approximately four or five times after she had used it.
- There was guidance in the manual that instructed staff how often and when they need to wipe down the prep table surface and when to change the sanitized/disinfectant solution.
- She should have wiped down the prep table surface when liquids spilled onto it with the sanitized/disinfectant solution but did not.

4. Record review of the facility's policy titled, "Proper Food Handling," revised 08/02/11 showed the following directive for staff: Hands must be washed before and after all glove use.

5. Observation on 08/25/15 at 10:40 AM showed Staff S, Dietary Manager, removed his gloves, put on another pair and began cooking pork chops in a pan. Staff S did not perform hand hygiene before he put on another pair of gloves to cook the pork chops. Then Staff S put bacon in a pan, removed his gloves and put on another pair without performing hand hygiene.

During an interview on 08/27/15 at 2:15 PM, Staff S, Dietary Manager, stated that:
- Staff are expected to wash their hands upon entry into the kitchen.
-Any time a staff changed tasks their gloves needed to be removed and hand hygiene performed.
- Any time gloves are removed hand hygiene needed to be performed.
-He did not perform hand hygiene when he removed his gloves times two but should have.
- He expected the dietary staff to follow the facility's dietary policies and procedures.

6. Observation of the cafeteria on 08/25/15 at 1:38 PM showed the following:
- No cover on a 35 gallon plastic trash container in the cafeteria's single entrance/exit contained garbage and trash.
- Splattered food debris on the ceiling of the microwave oven.
- Oil stains on open cardboard boxes of condiments located on a shelf below a central prep table in the kitchen.
- No cover on a 35 gallon plastic trash container at the end of the central prep table in the kitchen.
- Brown oily residue inside on the back walls, doors and windows of the Vulcan stack ovens.
- Oil residue on drip tray around the bottom rim of the range hood.
- Vulcan bi-level hot boxes, no longer working, were being used for miscellaneous storage.
- French fries, lumps of fried batter and grease deposits were on the splashboard on both sides of the deep fat fryer.
- Black and brown grease residue coated the interior walls, floor and plumbing to the gas burners in the fryer cabinet
- Grease residue on the back splash of the six burner stove and splash-plate separating the stovetop and deep fat fryer.
- Dense black deposits of oil, grease and dust, mixed with unidentifiable food debris on gas pipes and plumbing, floor and wall behind the stove, oven and deep fat fryer.
- Food crumbs and dark colored unidentifiable materials stuck in patches of exposed adhesive that remained stuck to the floor.
- Thirteen ceiling tiles in the kitchen were soiled with soot discharge from ceiling vents, soiled and stained brown from past water leaks, splattered debris, or damaged with scratches and gouges.

During interviews on 08/25/15 at 2:00 PM through 08/26/15 at 9:00 AM, Staff S, Dietary Manager acknowledged the findings and stated that he had only been there for 60 days, and still needed to further develop the current cleaning schedules, frequencies and job assignments. He stated that housekeeping staff only cleaned the floor in the cafeteria weekly. He stated that kitchen staff cleans up their areas after each meal and his current deep cleaning schedules assign each employee to tasks on a rotating basis, so that everything in the kitchen should be deep cleaned at least once weekly.

7. Observation of the walk-in freezer on 08/25/15 at 2:00 PM showed multiple icicles extended from the condenser unit down the back wall, where they pooled and froze into an ice flow on the floor at the back of the freezer. A package of green vegetables had spilled onto the ice and some of the product was embedded under the accumulated flows of ice on the floor. Two partially used half open cardboard boxes of pizza dough were on the floor. Significant accumulations of ice and white frost had formed on the freezer ceiling and on all bagged and boxed frozen products stored on the shelves.

Observation of the walk-in freezer on 08/26/15 at 3:30 PM showed no changes in the freezer's condition throughout the second day of observation. The icicles on the back wall were still present and unchanged, the frozen pooled ice flow with embedded green vegetables on the floor below the condenser unit was still there, half opened pizza dough boxes still on the floor, accumulations of ice on the ceiling were still present and a coat of thick white frost covered most of the products on the shelves.

During an interview on 08/25/15 at 2:00 PM, Staff S, Dietary Manager, stated that something was wrong with the defrost cycle and a part was on order. He stated that there was more food product in the freezer and the ice and frost looked much worse 60 days ago when he took the job. He stated that the pizza dough boxes on the floor were part of a shipment received earlier in the day that had not been put away yet. He stated that the outside freezer was scheduled to be swept and mopped weekly, but he did not have a policy or protocol to address the frost and ice buildup on the stored frozen food products, and ice on the ceiling, walls and floor.

During an interview on 08/26/15 at 9:55 AM, Staff R, Director of Facilities stated that he thought the defrost timer was not cycling correctly. He stated that he had made some adjustments and was waiting for the Dietary Manager to let him know if it had worked or not.



18018

Based on interview, record review and policy review, the facility failed to ensure that patients were screened for discharge risks for one current patient (#1) of one current patient's medical record reviewed, and for three discharged patients (#24, #26 and #27), of three discharged patients' medical records reviewed for a Discharge Risk Assessment. These failures had the potential to lead to the inability to recognize those patients in need of a discharge planning evaluation, which could cause delays in discharge, poor discharge outcomes, and readmission, and could affect all patients. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Discharge Planning," dated 05/2015, showed high-risk screening to identify patients who potentially need assistance with discharge planning/care transition was accomplished by the nurse during the initial nursing assessment at admission. It was called the Discharge Risk Assessment. Patients identified by the Discharge Risk Assessment would be referred to Social Services by the admitting nurse, by phone, to then have a Discharge Evaluation done by an in-depth assessment and interview.

2. Record review of a blank "Discharge Risk Assessment", showed questions related to a patient's living situation, mobility, medications, hospitalizations, family/friend support, ability to provide basic care for themselves, etc, and each answer was assigned a numerical value based upon the risks it could pose at discharge.

3. Record review of current Patient #1's medical record showed a History and Physical (H&P) which indicated the 96 year old patient was admitted on 08/07/15, with heart failure, a heart attack, low blood pressure and pneumonia, after he fell at an assisted living center where he resided. There was no Discharge Risk Assessment completed.

4. Record review of discharged Patient #24's medical record showed:
- A H&P which indicated the 92 year old patient was admitted on 06/21/15, lethargic (weak), with a history of arthritis (pain and inflammation of the joints), and a recent history of multiple falls. One fall resulted in the patient striking her head.
- A Discharge Summary which indicated the patient was discharged to skilled nursing on 06/24/15 with gait disturbance (difficulty walking safely).
- No Discharge Risk Assessment was completed.

5. Record review of discharged Patient #26's medical record showed:
- A H&P which indicated the 98 year old patient was admitted on 06/24/15 with high blood pressure, small bowel obstruction (SBO, where the small bowel becomes blocked, and gas/stool cannot pass), and arthritis. The patient lived alone.
- A discharge summary which indicated the patient was discharged home on 06/29/15.
- No Discharge Risk Assessment was completed.

6. Record review of discharged Patient #27's medical record showed:
- A H&P which indicated the 81 year old patient was admitted on 07/02/15, lethargic, with developing/acute pancreatitis, nausea, vomiting, with a history of high blood pressure, seizure disorder.
- A Discharge Summary which indicated the patient was discharged home on 07/04/15.
- No Discharge Risk Assessment was completed.

During an interview on 08/25/15 at 1:15 PM, Staff BB, Patient Navigator, stated that the Discharge Risk Assessment should be completed upon patient admission for every admission, but nursing did not document the Discharge Risk Assessment on Patients #1, #24, #26, and #27.

During an interview on 08/25/15 at 9:15 AM, Staff AA, Manager of Medical/Surgical (Med/Surg) Department, stated that a Discharge Risk Assessment was developed in the electronic medical record, and there was discussion that at some point nursing staff would complete the Discharge Risk Assessment, but the process was never put into place.

During an interview on 08/26/15 at 8:50 AM, Staff II, Registered Nurse (RN), Director of Quality, stated that all acute inpatients are to receive a discharge risk assessment from the Navigator RN (nursing staff that is responsible for patient discharge risk assessments and plans). Staff II stated that the Discharge Multidisciplinary Team meets every morning to discuss discharge needs of patients. Staff II stated that the facility did not have a policy or procedure that guided staff when the discharge risk assessment needed to be completed by after the patient was admitted. Staff II stated that she has not collected data to ensure staff had documented discharge risk assessments or plans in patients' medical records.

During an interview on 08/27/15 at 9:10 AM, Staff LL, Charge RN, stated that nursing did not complete the Discharge Risk Assessment upon patient admission or anytime during the patient's stay. Staff LL added that she assessed a patient's discharge risks based on if the patient had received home health services in the past.








18018

Based on interview, record review and policy review, the facility failed to ensure that patients received a discharge planning evaluation for one current patient (#1) of one current patient's medical record reviewed, and two discharge patients (#24, and #26), of three discharged patients' medical records reviewed for a discharge planning evaluation. These failures had the potential to lead to delays in discharge, poor discharge outcomes, and readmission, and could affect all patients. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Discharge Planning," dated 05/2015, showed high-risk screening to identify patients who potentially need assistance with discharge planning/care transition is accomplished by the nurse during the initial nursing assessment at admission. It is called the Discharge Risk Assessment. Patients identified by the Discharge Risk Assessment will be referred to Social Services by the admitting nurse by phone to then have a Discharge Evaluation done by an in-depth assessment and interview.

2. Record review of a blank "Discharge Risk Assessment", showed questions related to a patient's living situation, mobility, medications, hospitalizations, family/friend support, ability to provide basic care for themselves, etc., and each answer was assigned a numerical value based on risk it could pose at discharge. The form also showed that if the patient's total score was 10 or greater, the patient was to be referred to the discharge planning coordinator or discharge planning team, for a Discharge Evaluation.

3. Record review of current Patient #1's medical record showed:
- A History and Physical (H&P) which indicated the 96 year old patient was admitted on 08/07/15, with heart failure, a heart attack, low blood pressure and pneumonia, after he fell at an assisted living center where he resided.
- No Discharge Risk Assessment was completed. However, based on information in the record, the patient would have scored a 13 on the Discharge Risk Assessment, which would have referred the patient for a Discharge Evaluation.
- There was no Discharge Evaluation completed.

4. Record review of discharged Patient #24's medical record showed:
- A H&P which indicated the 92 year old patient was admitted on 06/21/15, lethargic (weak), with a history of arthritis (pain and inflammation of the joints), and a recent history of multiple falls. One fall resulted in the patient striking her head.
- A Discharge Summary which indicated the patient was discharged to skilled nursing on 06/24/15 with gait disturbance (difficulty walking safely).
- No Discharge Risk Assessment was completed. However, based on information in the record, the patient would have scored a 16 on the Discharge Risk Assessment, which would have referred the patient for a Discharge Evaluation.
- There was no Discharge Evaluation completed.

5. Record review of discharged Patient #26's medical record showed:
- A H&P which indicated the 98 year old patient was admitted on 06/24/15 with high blood pressure, small bowel obstruction (SBO, where the small bowel becomes blocked, and stool cannot pass), and arthritis. The patient lived alone.
- A discharge summary which indicated the patient was discharged home on 06/29/15.
- No Discharge Risk Assessment was completed. However, based on information in the record, the patient would have scored a 10 on the Discharge Risk Assessment, which would have referred the patient for a Discharge Evaluation.
- There was no Discharge Evaluation completed.

During an interview on 08/25/15 at 9:15 AM, Staff AA, Manager of Medical/Surgical (Med/Surg) Department, stated that a Discharge Risk Assessment was developed in the electronic medical record, and there was discussion that at some point nursing staff would complete the Discharge Risk Assessment, but it never went further than discussion.

During an interview on 08/26/15 at 8:50 AM, Staff II, Registered Nurse (RN), Director of Quality, stated that all acute inpatients are to receive a discharge risk assessment from the Navigator RN (nursing staff that is responsible for patient discharge risk assessments and plans). Staff II stated that the Discharge Multidisciplinary Team meets every morning to discuss discharge needs of patients. Staff II stated that the facility did not have a policy or procedure that guided staff when the discharge risk assessment needed to be completed by after the patient was admitted. Staff II stated that she has not collected data to ensure staff had documented discharge risk assessments or plans in patients' medical records.

During an interview on 08/27/15 at 9:10 AM, Staff LL, Charge Registered Nurse (RN), stated that nursing did not complete the Discharge Risk Assessment upon patient admission or anytime during the patient stay. Staff LL added that she assessed a patient's discharge needs based on if the patient had received home health services in the past.

During an interview on 08/25/15 at 1:15 PM, Staff BB, Patient Navigator, stated that the Discharge Risk Assessment should be completed upon patient admission for every admission, but nursing did not document the Discharge Risk Assessment on Patients #1, #24, and #26. Staff BB stated that the Discharge Risk Assessment score was the trigger for a Discharge Evaluation to be completed by her (Staff BB) or Social Services. During the interview, Staff BB recognized that the Discharge Evaluation process were not completed on any acute care patients, but only on swing bed patients (post-acute extended care), that the Discharge Evaluation was not maintained in the patients record, but shredded sometime after the patient was discharged.





18018

Based on observation, interview, record review, and policy review, the facility failed to ensure High Standards of Care for surgical services were developed and followed for two current patients (#2 and #28) and for four discharged patients (#30, #31, #35, and #38) of seven surgical out patient records reviewed for the following:
- Developed, established, approved and written clinical pre-operative (pre-op) criteria and discharge criteria was documented for two current patients (#2 and #28) and for four discharged patients (#30, #31, #35 and #38 ).
- Patient discharge instructions were accurate and provided current information for two patients (#30 and #31).
- Medical Staff Executive Committee (MEC), which included the Chief of Surgical Services and Chief of Medical Staff, approved all surgical services equipment, processes, protocols and anesthesia forms.
These failures had the potential to affect all patients who receive surgical services. The facility conducted 59 surgical procedures during the five month period which preceded the survey. The facility census was one.

Findings included:

1. Record review of the facility's Surgical Services policy and procedures manual and the "Table of Contents", dated 08/2014 , showed no policy and procedures that provided guidance for the following surgical standards of care:
- The required protocol or documentation for surgical patients' pre-op criteria;
- The protocol, policy, procedure and/or scope of service required for admitted/scheduled patients for surgical procedures; and
- Appropriate protocols for all surgical procedures performed.

2. Observation on 08/25/15 at 7:45 AM of Patient #2 in the patient room designated for pre-operative (pre-op) patient procedures, showed Staff K, Certified Registered Nurse Anesthetist (CRNA), conducted an assessment, interviewed the patient, discussed the anesthesia procedures, reviewed the chart and obtained consents on a form that did not have information designated as a facility form. The form appeared generic without facility identification.

3. During an interview on 08/25/15 at approximately 7:50 AM, Staff K, CRNA, stated that he conducted the anesthesia pre-op assessment prior to administration of anesthesia and made sure that the patients were appropriate for anesthesia. He stated that he developed his own patient criteria for risk factors of anesthesia administration. Staff K stated that he regularly used a form he brought to the facility to document the assessment of risk factors prior to administration of anesthesia. He stated that he did not know if the form had been approved.

4. During an interview on 08/25/15 at approximately 7:40 AM, Staff L, Registered Nurse (RN) stated that she placed Patient #2's IV (intravenous, small catheter inserted in a blood vessel for the administration of medication and fluids) and administered IV fluid. She further stated that she had previously started many of the pre-op patient IV's. However, Staff L could not locate a physician's order or a pre-op protocol in the patient's medical record for Patient #2's IV or for the administered IV fluid. Staff L stated that she knew that a physician order was required for the IV placement and for administered medications which included IV fluids. However, she thought the Surgery Department had policies, procedures and protocols and that the orders would have been in the patient's medical record for pre-op procedures.

5. During an interview on 08/25/15 at approximately 7:55 AM, Staff F, Manager of Surgical Services, stated that she was aware of the requirement for pre-op protocols. However, she stated the facility did not use them for surgical patients.

6. During an interview on 08/25/15 at approximately 8:00 AM, Staff E, Physician/Surgeon, stated that he considered the information documented by the nurses pre-operatively was good and that he reviewed their assessment and if he saw a problem he would document his finding. He stated that he wasn't aware that the nurses didn't have pre-op protocols. He stated that he knew all of his patients well and would know if they had problems that would not make them suitable for surgery.

7. During a concurrent interview in the Post Anesthesia Care Unit (PACU, a unit where patients were transferred to after a surgical procedure) on 08/25/15 at 9:30 AM, Staff H, Staff J, and Staff L, RN's who provided patient care for current out patient surgical Patient #2, stated that there were no written protocols or standing physician orders for pre-op or discharge criteria. They just knew what to do.

8. During an interview and concurrent review of facility records on 08/25/15 at 9:35 AM, Staff F stated that the discharge criteria was written in a policy. However, the policy applied to all patients and informed staff to discharge patients when their vital signs were within 20% of the baseline. She stated that written discharge criteria should be specific to the surgical procedure, approved by the physician, and placed in the medical record. She stated that no policies had been developed for the physicians surgical standards, the information was written in the Medical Staff Rules and Regulations and also were required by regulation as surgical standards. She provided copies of the Code of federal Regulations and also a copy of the Medical Staff Rules and Regulations which provided required standards for surgical care. She stated "it was up to the physicians what they chose to do".

9. Record review of current Patient #2's Medical Record showed:
- The patient arrived to the facility on 08/25/15 at 7:00 AM for the surgical procedures; laparoscopic tubal cauterization (surgical procedure whereby the surgeon entered the abdomen and altered the tubes from the ovaries to the uterus) and endometrial ablation (a procedure that destroys [ablates] the uterine lining).
- No pre-op protocol; and
- No discharge criteria.

10. Observation in the surgical operation suite (OR) on 08/25/15 at 8:00 AM through 9:25 AM of Patient #2's surgical procedure showed the patient's surgical procedure was interrupted because of equipment malfunction. Staff E, Staff F, Staff HH, and Staff I, Scrub Technician (scrub tech)/Manager of Central Sterile Processing conducted more than five separate and different attempts to correct the malfunction and obtain needed equipment prior to successful return to use. Staff F exited the OR three separate occasions to obtain needed equipment.

During an interview on 08/25/15 at approximately 9:20 AM, Staff I stated that no protocol or procedure was developed for the use of the equipment.

11. Record review of Patient #28's Medical Record showed the patient arrived to the facility on 08/25/15 at 9:00 AM for the surgical procedures; laparoscopic tubal cauterization and endometrial ablation. No pre-op criteria/protocol or discharge criteria was documented.

12. Record review of Patient #30's medical record showed:
- The patient arrived to the facility on 04/08/15 at 1:36 PM for a surgical procedure to relieve lower back pain;
- A discharge instruction sheet that informed the patient, in the event of complications or concerns to contact a distinctly different facility; and
- No discharge criteria documented.

13. Record review of Patient #31's medical record showed:
- The patient arrived to the facility on 05/13/15 at 12:15 PM for a surgical procedure to relieve lower back pain;
- A discharge instruction sheet that informed the patient, in the event of complications or concerns to contact a distinctly different facility; and
- No discharge criteria documented.

14. Record review of Patient #35's medical record showed:
- The patient arrived to the facility on 06/23/15 at 9:00 AM for a surgical procedure to explore the urinary tract and obtain tissue for a biopsy (evaluation and identification of abnormal growth);
- No documented pre-op protocol; and
- No discharge criteria documented.

15. Record review of Patient #38's medical record showed:
- The patient arrived to the facility on 07/24/15 at 7:45 AM for a surgical procedure to the eyes;
- No physician pre-op protocol; and
- No discharge criteria documented.

16. During an interview and concurrent review of Patient #2's medical record on 08/26/15 at 12:45 PM, Staff DD, Physician Director of Surgical Services and Chief of Medical Staff, stated that:
- He could not recall approval for the use of the form used by the CRNA to document their assessment.
- He was not aware that protocols for all surgical services were not developed and /or approved for; pre-op procedures, unique clinical procedures, use of equipment, admission criteria, and discharge criteria.
- Protocols, policies/procedures and written requirements were essential to meet the standard of care for surgical patients.

Based on observation, record review and interview, the facility failed to ensure Physicians performed patient History and Physical (H&P) examinations for two current out patient surgical patients (#2 and #28) and four discharged out patient surgical patients (#30, #31, #34, and #37)) of seven patients medical records reviewed. These failures had the potential to cause all surgical patients harm or injury related to unidentified needs and/or risk factors by a qualified physician prior to a surgical procedure through the H&P. An average of 12 surgical procedures were performed monthly. The facility census was one.

Findings included:

1. Record review of the facility's Medical Records Department's policy titled, "History and Physical," dated 05/2014, showed the following direction:
- The H&P shall be completed by the physician, in all cases, prior to a surgical procedure.
- When an H&P is not present on the record at the time of the stated surgical procedure, the procedure shall be canceled.
- Physicians shall, at a minimum, record all elements of the physician H&P.

Record review of the facility's Rule's and Regulation's of the Medical Staff," dated 06/2013, showed:
-The physician was responsible for all medical care and treatment of each patient.
- The physician was responsible for completeness and accuracy of the medical record.
- A complete H&P was required for Podiatry (patients who received foot surgery).
- An H&P was performed by a Physician and recorded before a surgical procedure.

2. Observation on 08/25/15, which began at 7:10 AM through approximately 8:00 AM of Patient #2 in the patient room designated for pre-operative patient procedures, showed the following:
- At approximately 7:10 AM, Staff H, Registered Nurse (RN) conducted the patient's nursing assessment and received assistance from Staff J, RN. Staff H documented the assessment on the form titled "Medical History".
- At approximately 7:35 AM, Staff F, Manager of the Surgical Services department conducted a brief interview with the patient focused on the risks of the surgery.
- At approximately 7:45 AM, Staff K, Certified Registered Nurse Anesthetist (CRNA), conducted a physical examination, interviewed the patient, discussed the anesthesia procedures, reviewed the chart and obtained consents.
- At approximately 8:00 AM, Staff E, Physician and Surgeon, observed the patient while in bed and asked her if she was "ready for the procedures". Staff E did not perform a physical examination.

3. Record reviews of two current surgical Patients #2 and #28 and four discharged Patients #30, #31, #34, and #37 showed no physician H&P examination prior to surgical procedures which included podiatry surgical procedures.

During an interview on 08/25/15 at approximately 7:25 AM, Staff H and Staff J stated that the RN's conduct the assessments on patients pre-operatively and that they fill out the Medical History form and the physician signed them. Staff H and Staff J stated that the nursing assessments were the same thing as the H&P.

During an interview on 08/25/15 at approximately 7:50 AM, Staff K, CRNA, stated that H&P's were not usually in the patients' medical records when he conducted the anesthesia pre-op assessment prior to administration of anesthesia. Staff K stated that he regularly used a form he brought to the facility to document the physical assessment and the risks related to administration of anesthesia and that the form was kept in the patients medical record. He stated that he was required to review the H&P and if a physicians H&P was not on the chart, he performed a physical assessment and assessed the patients history. He stated that the RN's assessment was not the same as a physician performed H&P.

During an interview on 08/25/15 at approximately 7:55 AM, Staff F, Manager of Surgical Services, stated that she was aware of the requirement for a physician conducted H&P to be completed and updated prior to a surgical procedure. She stated that the nurses completed the Medical History form and that was considered the H&P. She instituted the Medical History form in response to patients not getting H&P's prior to surgical procedures. She stated that she had tried to get the physicians to comply with the requirements and was not successful. She stated that the form had been approved for use by the Forms Committee and did not know if a physician was a member of the committee. She stated that she wasn't sure if the Physician Director of Surgical Services had approved the form for use.

During an interview on 08/25/15 at approximately 8:00 AM, Staff E, Physician/Surgeon, stated that he reviewed the Medical History form conducted by the RN's for Patient #2 and he considered the RN's assessment and documentation as good as and the same as a physicians H&P. He stated that he knew all of his patients well and would know if they had any problems that would not make them suitable for surgery.

During an interview and concurrent review of Patient #2's medical record on 08/26/15 at 12:45 PM, Staff DD, Director of Surgical Services and Chief of Medical Staff, stated that:
- He was not familiar with the Medical History form (completed by nurses);
- He could not recall approval of the Medical History form or the use of the form as the Physician H&P.
- Physicians were expected to perform all patient H&P's and the H&P's for surgical patients should be conducted prior to surgical procedures and updated the day of surgery by the physician who provided the surgical service. H&P's should be dictated and placed in the medical record.
- He was not aware H&P's for surgical patients were not performed by the physicians, that the H&P's were not in the medical record or that obtaining H&P's was a problem.
- H&P's were essential to avoid problems that the physicians were trained to identify and physician performed H&P's met the standard of care for surgical patients.
- The CRNA's assessment did not replace a physician's H&P.

Based on record review, interview and policy review, the facility failed to ensure Physicians completed a required Operative Report/Surgical Procedure Summary (Surgical Summary)for two current out patient surgical patients (#2 and #28) and for four discharged patients (#30, #31, #34, and #35) of seven surgical out patients records reviewed who received out patient surgical procedures. These failures had the potential to cause harm or injury to all patients who received surgical services related to the lack of detailed information to ensure continuity of care and accurate surgical histories. The facility performed an average of 12 out patient procedures monthly. The facility census was one.

Findings included:

1. Record review of the facility's "Rules and Regulations of the Medical Staff," dated 06/2013, showed:
-The physician was responsible for all medical care and treatment of each patient.
- The physician was responsible for completeness and accuracy of the medical record.
- Operative reports (Surgical Summaries) included a complete detailed account of the findings of surgery, details of the surgical technique and all patient care and outcomes.

2. Record reviews of two current out patient surgical Patients #2 and Patient #28 and four discharged out patient surgical Patients #30, #31, #34, and #35 showed no completed detailed Surgical Summary/Operative Report which contained the required detail of findings of surgery, details of the surgical technique and all patient care and outcomes.

During an interview on 08/26/15 at approximately 11:00 AM, Staff F, Manager of Surgical Services, stated that the surgical standards for Surgical Summaries required specific detailed components of each patients surgical procedure technique and should contain a detailed record of everything that "happened to the patient during surgery". She stated that she developed a form with required components and encouraged the physicians to complete a detailed surgical summary. However, she stated that she was aware that the summaries were not detailed and not complete. She stated that each physician did things "their own way".

During an interview and concurrent review of Patient #2's medical record on 08/26/15 at 12:45 PM, Staff DD, Director of Surgical Services and Chief of Medical Staff, stated that the "standard" for all signed Surgical Summaries/Operative reports included a detailed account of the findings of surgery and provided detailed information related to the surgical technique. He stated that the surgical summary should be detailed and describe everything that was performed and what happened to the patient during surgery. He stated that he did not think Patient #2's signed surgical summary information was complete and that it contained what was expected by the Medical Staff Rules and Regulations and should be improved. However, "All physicians like to do it their own way".

During an interview and concurrent review of Patient #2's Surgical Summary on 08/26/15 at 12:50 PM, Staff Q, Chief Nursing Officer (CNO) stated that complete and detailed Surgical Summaries were very important to the continuity of any surgical patients care and that he was unaware physicians had not completed the detailed Summaries.

Based on interview, record review, and policy review, the facility failed to ensure that staff maintained required competency, according to policy, in Arterial Blood Gas (ABG, blood test that measures the acidity and the levels of oxygen and carbon monoxide in the blood) testing for five staff (Y, EE, VV, WW and XX) of 11 staff competencies reviewed. This failed practice had the potential to lead to potential injury to patients and incorrect results during the ABG testing process, which could affect any patient whose ABGs were tested. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Blood Gas Chemistry Training," dated 01/26/2015, showed:
- All employees who are required to perform arterial blood gasses as part of their job duties will be required to complete an orientation checklist and a periodic employee competency checklist.
- Every year as a part of their yearly evaluation they will be observed by their peers to prove their competency and fill out a periodic employee competency checklist.
- All of the current periodic competencies will be kept in the Emergency Department with the Blood Gas Chemistry policy and procedure manual, which is kept by the Blood Gas Analyzer (machine used to test blood gases).
- Outdated competencies will be kept in a competency folder located in the Respiratory Therapy Department.

2. Record review on 08/26/15, of the Blood Gas Chemistry Manual located with the Blood Gas Analyzer, showed:
- Staff Y, Registered Nurse (RN), with an expired competency dated 05/12/14;
- Staff EE, RN, with an expired competency dated 04/21/14;
- Staff VV, RN, with an expired competency dated 04/07/14;
- Staff WW, RN, with an expired competency dated 05/22/14; and
- Staff XX, Respiratory Therapy (RT) Director, with an expired competency dated 04/07/14.

During an interview on 08/26/15 at 11:00 AM, Staff Y stated that she was the only RN working in the Emergency Department at that time. Staff Y stated that she was responsible for ABG draws and testing, because there was no other RN working in the ED and because RT was off for the day. Staff Y stated that she was unsure how ABG competency was completed, but believed that Staff XX "just came around [to the ED] and completed competencies". Staff Y was unaware if she was current on her ABG competency.

During an interview on 08/26/15 at approximately 3:30 PM, Staff X, Emergency Department Manager, stated that if staff were "running [testing] ABGs, then they should be competent".

3. Record review of ABG results from 06/2015 through 07/2015, showed Staff XX completed ABG patient testing on 06/30/15, two times on 07/06/15, on 07/21/15 and on 07/20/15, and Staff Y completed ABG patient testing on 06/24/15.

During an interview on 08/26/15 at 9:45 AM Staff P, Laboratory Manager, stated that ABG user competency was the only citation issued during a recent CLIA (Clinical laboratory Improvement Agency, a federal regulatory agency that inspects laboratories) survey. Staff P stated that he was disappointed that it wasn't fixed.

During an interview on 08/26/15 at 12:50 PM, Staff Q, Chief Nursing Officer, stated that Staff X and Staff XX were both responsible to ensure nurses were competent in ABG testing, and added that he (Staff Q) was ultimately responsible for ensuring staff competency, since both Staff X and Staff XX reported to him.

Based on observation, interview, record review, and policy review the facility failed to ensure that the Activities Coordinator was qualified and conducted a therapeutic activity program designed specifically to meet the individual needs of each patient for one patient (#1) of one patient reviewed. This had the potential to deny all patients in the Swing Bed Program (post-acute, skilled nursing care) of their physical, mental and social functionality. The facility census was one.

Findings included:

1. Record review of the facility's policy titled, "Therapeutic Activities," revised 02/2014, showed the following: It is the function of the Therapeutic therapy to provide for the needs of the "whole person". The purpose of the activities is to habilitate and/or rehabilitate the patient's physical, mental, and social functionability.
- To contribute to the patient's rehabilitation or prevent further deterioration.
- To provide alternatives to compensate for loss of mental, social, and physical capacities.
- To provide a planned schedule of recreational, social, educational, and therapeutic activities.
- To provide to the needs of the whole person.
- To learn new skills and relearn old ones through games, crafts, and projects.
- To achieve a positive self-image through success brought about by tailoring the activity to the patient's abilities.
- To aid the client to develop the attitude and leisure skills that the client can continue outside the therapeutic setting through exposure to and participation in a variety of activities.

Record review of the facility's policy titled, "Activities," reviewed 05/2014, showed the following:
-An ongoing program of meaningful activities is provided based on identified needs and interests of each resident. It is designed to promote opportunities for engaging in normal pursuits, including religious activities of their choice, if any.
- The activities promote the physical, social, and mental well-being of the resident.
- Assessment will include: a. Patient's use of free time. b. Preadmission hobbies and interests. c. Ability to participate in group/individual activities. d. Indicate intervention to enhance activities.

2. Record review of the facility's Job Description titled, "Activities Coordinator," dated 03/2008, showed the following:
- Plans, organizes, and conducts recreational, therapeutic, and social activities including group activities and games, outings, crafts and projects, and social events to maintain and enhance residents independence, self-worth, and mental and physical skills and abilities.
- Responsible for the accurate and proper documentation of resident records.
- Certification in Long Term Care (LTC) Activities through the state of Missouri required either at the time of employment or within one year of employment. (This is contradictory to the regulatory requirements).

3. Record review of Patient #1's medical record did not contain an activity assessment. Patient #1 had been admitted to the facility on 08/07/15 as a Swing Bed Patient.

During an interview on 08/24/15 at 3:00 PM, Patient #1 stated that he enjoyed exercising, church services, and Fox and Friends on television. He stated that he did like to read but only had a two day old newspaper. He stated that no one had talked to him about activities and that he had not been to any activities.

During an interview on 08/25/15 at 09:12 AM, Staff C, Social Services Designee/Activities Coordinator, stated that she was made Activities Coordinator on 06/22/15 and had no orientation or training for the position. She stated that whenever there were activities going on she invited Patient #1 or asked if he wanted to attend. She stated the activity schedule "Was not great, I just follow the old schedule that was already here". She stated that she assessed all new patients. Staff C stated that she didn't do anything different for Patient #1 than she did for the long term care residents and he did not have an individualized activity calendar. She stated that she had just learned that there was an electronic assessment tool but hadn't used it so any assessments would be hand written in the patient's medical record.

During an interview on 08/25/15 at 1:55 PM, Staff U, Certified Nursing Assistant (CNA), stated that the Activity Log was in the Nurses' station. She stated that each patient's monthly calendar is in the log and that if they attend an activity then that activity is circled on the calendar. The Activity Log contained no entries since January 2015.

4. Record review of the Activity Calendar for August 2015 showed that no activities were provided on Saturdays or Sundays. The only activity provided on Tuesdays was church. The only activity provided on Thursdays was Beauty Shop which is not considered an activity by regulatory standards.

During an interview on 08/25/15 at 2:15 PM, Staff Q, Chief Nursing Officer (CNO), stated that he was aware that Staff C was not a qualified Activities Coordinator. He stated that the position had been vacant since January 2015 until Staff C was appointed in June 2015. He stated that he was not aware that patients were not provided assessments or individualized activities.