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Based on interview and record review, the facility failed to adhere to their established Medical Staff Rules and Regulations for obtaining written physician orders for continued use of physical restraint (any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the patient's ability to freely move arms, fingers, legs, body or head) beyond the first twenty four hours for three (#14, #30, #35) of three patients reviewed for restraint use. This deficient practice had the potential to permit staff to physically restrain any patient without a renewal of a physician's order and assessment of medical need. The facility census was 46 with three of those in physical restraints.

Findings included:

1. Record review of the facility's document titled, "Medical Staff Rules and Regulations," approved 12/06/13 showed directives for the medical staff to document a new written order for continued restraint use, every calendar day, in the patient's medical record, based on a physical examination of the patient, by a Licensed Independent Practitioner (LIP, another physician or a nurse practitioner who provides patient care, within their scope of practice and without the direct supervision of a physician).

2. Record review of Patient #14's restraint documentation showed the following:
- The form titled, "Restraint Initiation/Order (Non-Violent Non-Self Destructive Behavior) dated 02/25/15 showed staff initially applied soft wrist restraints to Patient #14 on 02/25/15;
- The forms titled, "Restraint Monitoring (Non-violent, Non-self destructive Behavior) showed staff documented the patient remained in restraints from 02/25/15 through 04/01/15 (36 days); and
- Only three other "Restraint Initiation/Order" forms, dated 03/10/14 (misdated, should have been 03/10/15); 03/17/15 and 03/31/15 documented the physician's orders for continued use of physical restraints.

3. Record review of Patient #30's restraint documentation showed the following:
- The form titled, "Restraint Initiation/Order" dated 03/30/15 showed staff initially applied soft wrist restraints to Patient #30 on 03/30/15;
- The forms titled, "Restraint Monitoring" showed staff documented the patient remained in restraints from 03/30/15 through 04/01/15; and
- Staff failed to obtain physician's orders for continued restraints dated 03/31/15 and 04/01/15.

4. Record review of Patient #35's restraint documentation showed the following:
- The form titled, "Restraint Initiation/Order" showed staff initially applied soft wrist restraints to Patient #35 on 03/18/15;
- The forms titled, "Restraint Monitoring" showed staff documented the patient remained in restraints from 03/18/15 through 04/01/15 (15 days); and
- Only three other "Restraint Initiation/Order" forms, dated 03/24/15; 03/28/15 and 03/31/15 documented the physician's orders for continued use of physical restraints.

During an interview on 04/01/15 at 12:50 PM, Staff M, Clinical Nurse Specialist (CNS) confirmed that the current process for restraint orders included obtaining a physician's order for continued use of physical restraint as directed in the Medical Staff Rules and Regulations.

Based on observation, interview, record review and policy review, the facility failed to:
- Thoroughly assess and/or re-assess patients with falls and initiate a fall prevention care plan a timely manner for one (#5) patient, and revise and/or utilize individualized interventions to prevent falls, for two (#5 and #31) of two patients reviewed with falls.
- Thoroughly complete the Notification of a Change in Condition documentation and/or all sections of the After-Fall Assessment Worksheet, for two (#5 and #31) of two patients' reviewed, which could potentially prevent future falls.
- Assess one (#31) patient for the appropriate implementation of a bed alarm (a mechanical device that emits an audible sound warning staff the patient is attempting to get out of bed) to prevent potential falls. These failures had the potential to place all patients admitted to the facility at risk for repeated falls. The facility census was 46.

Findings included:

1. Record review of the facility's policy titled, "Assessment/Re-Assessment-Interdisciplinary Patient," dated 02/2014, directed the Registered Nurse (RN) to do the following:
- The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care is developed by the RN based on identified problems and patient specific needs.
- The admitting RN will screen each patient to identify fall risk.
- A re-evaluation of the patient shall occur, at a minimum of once every 12-hours by a licensed nurse, based on the level of care and patient care needs.
- An RN directs the patient care through delegation and supervision.
- All nursing assessments are recorded in the patient record.
- An example of a significant change in condition (requiring Notification of a Change in Condition documentation) includes any situation in which the nurse feels uncomfortable with the patients condition and/or response to treatment.

Record review of the facility's policy titled, "Falls Prevention," dated 08/2014, showed the following:
- All patients will have standardized fall prevention interventions.
- A fall risk score of ten or above indicates the patient is a high risk for falls. Additional interventions will be added to their care plan to prevent falls. These may include a "risk for falls" sign/device (falling star, falling leaves, bracelets) to communicate the risk to all caregivers, bed alarms, floor mats, rehab evaluation, and use of low beds.
- Fall risk will be re-evaluated weekly.
- When a fall occurs, regardless of the risk score, additional interventions will be added.
- Complete an investigation after a fall using the After-Fall Assessment Worksheet.
- Nursing leadership analyzes the results of the fall investigations.

2. During an interview on 03/31/15 at 9:50 AM, Staff M, Clinical Nurse Specialist, stated that RN staff assessed patients' fall risk every Wednesday. Staff M stated that if a patient fell, a Notification of a Change in Condition should be documented by the RN, followed by the completion of an After-Fall Assessment Worksheet. This documentation, along with the event report (an internal tracking report), was evaluated by the Supervisor, quality personnel, and the leadership team every morning to determine possible changes in care.

3. Record review of Patient #5's History and Physical (H & P) dated 02/10/15, showed the patient was admitted on 02/09/15 with diagnoses of traumatic brain injury, multiple fractures, and he had a circular, surgical steel device screwed to his head called a halo (this device could cause poor balance related to the extra weight on the head).

Record review of Patient #5's fall risk assessment dated 02/09/15, showed a score of "10," or a high risk for falls.

Record review of After-Fall Assessment Worksheet documentation showed the following:
- The patient fell on 02/10/15 at 1:15 AM. The patient had been restless. The actions taken section showed, "neuro checks were in place" (assessment of the patient's level of consciousness and ability to follow direction). The Worksheet showed no falling star sign was on the patient's door (an indicator to staff the patient was a high fall risk) even though his fall risk score identified the need for one. The section indicating the care plan was updated was left blank.
- On 02/19/15 the patient was very restless. The actions taken section showed, "neuro checks in place." The Worksheet showed no falling star sign was on the patient's door, after two falls. The section indicating the care plan was updated was left blank.
- On 02/20/15 the patient was restless. The actions taken section showed, "Neuro checks, supervisor notified" (even though the patient had fallen three times, the only action taken was neuro checks). The Worksheet showed multiple blank sections, including was a falling star sign on the door, was the bed in the lowest position, was the care plan updated, and what the team determined the fall was related to.
- On 02/22/15 the patient was agitated and found on the floor sitting in bowel movement. The section about what the team determined the fall was related to was blank.
- On 02/23/15 the patient had leg spasms that increased the potential for sliding out of bed.
- On 03/19/15 the patient slid out of bed onto his buttocks. The actions taken section showed, "assessed passive range of motion done, vital signs taken." The section about what the team determined the fall was related to was blank.

Record review of Notification of Change of Condition documentation showed the following:
- On 02/19/15 at 11:40 PM, the patient managed to swing his legs off of bed and landed on his knees beside the bed.
- On 02/20/15 at 1:15 AM, the patient was found sitting at the side of the bed on the floor.
- On 02/22/15 at 11:50 AM, the patient was found sitting at the side of the bed on the floor.
- On 02/23/15 at 2:40 PM, the patient fell (no specific information documented).
- On 03/19/15 at 12:00 PM, the patient slid out of bed to the floor on his buttocks.
- Staff failed to document a Notification of Change in Condition for the fall on 02/10/15.

Record review of the patient's Kardex (an overview of the patient's care/problems) as of 03/31/15, showed he had fallen five times since admission (on 02/19, 02/20, 02/22, 02/23, and on 03/19/15). The fall risk score on the Kardex was "9" even though he had a history of falls. Staff failed to document the fall on 02/10/15.

Record review of the patient's care plan on 03/31/15, showed the following:
- Potential for injury related to history of previous falls and impaired mobility was initiated on 02/20/15, or ten days after his first fall on 02/10/15.
- The goal stated he would have no falls through 04/05/15.
- Interventions included providing adequate light, use of a high/low bed with floor mats, and implement safety measures.
- On 02/23/15, interventions of implement precautions related to sensory deficits, and staff will monitor with continuous observation during times of increasing activity, thrashing, and flailing in bed were added. The goal did not change even though the patient had fallen four times.
- No further interventions and/or goals had been/revised as of this review.

Observation and concurrent interview on 03/31/15 at 10:50 AM, showed the patient's bed in the lowest position, or approximately two feet from the floor (falling from this height could potentially still cause an injury). Staff P, Certified Nurse Assistant (CNA), confirmed this was the lowest this bed would go. Staff P stated that the patient was typically very active/spastic, swinging his legs and arms, flinging himself on the floor. There were no floor mats beside the bed, as directed by the care plan. Staff P stated that she did not put the floor mats beside the bed as long as she, or someone else was in the room with the patient (contrary to the care plan).

During an interview on 03/31/15 at 1:27 PM, Staff X, RN Supervisor, stated that the After-Fall Assessment Worksheet was designed to prevent future falls. The RN assigned to the patient was to complete the Notice of Change in Condition and the After-Fall Assessment Worksheet and send them to the Risk Manager so trends could be identified and changes in care made to prevent further falls. Staff X confirmed someone failed to document the 02/10/15 fall appropriately. Staff X stated that Patient #5 fell out of bed on 03/19/15 in spite of having a CNA in the room at the time.

During an interview on 03/31/15 at 4:20 PM, Staff R, Director of Quality, confirmed that the After-Fall Assessment Worksheet did not get completed for the 02/10/15 fall, which in turn caused the failure to update the care plan with appropriate interventions.

4. Even though requested, a specific policy regarding bed alarm use, completion of the After-Fall Assessment Worksheet, and care plans were not provided.

5. Record review of Patient #31's H & P dated 02/21/15, showed the patient was admitted on 02/20/15 with a diagnosis of muscle weakness.

During an interview on 04/01/15 at 9:10 AM, Patient #31 stated that she had fallen out of the bed, to her knees, several days prior.

Record review of Patient #31's nursing admission assessment, dated 02/20/15, showed the following:
- The patient had lower extremity edema (swelling which could cause difficulty standing/walking) and weakness.
- The patient took high risk medications (antianxiety and pain medications that could cause drowsiness and dizziness, contributing to falls).
- The patient had an unstable balance.
- The patient forgot instructions.
- The patient's fall risk score was "12."

Record review of the patient's care plan dated 02/20/15, showed the following:
- Potential for injury related to age, impaired physical mobility, and unfamiliar surroundings.
- A goal that she would be free of falls through 04/12/15.
- No interventions until 03/16/15. Then, one for a bed alarm.

Record review of the Notice of Change in Condition documentation showed the following:
- On 02/28/15, the patient was found sitting on the floor next to her bed.
- On 03/15/15, the patient was found on a mat on the floor next to her bed.
- Patient #31 had a right knee abrasion (scrape).

Record review of After-Fall Assessments for Patient #31 showed the following:
- On 02/28/15, at 3:00 PM, the patient was found on the floor. The sections about the falling star sign on the door and did the patient have a history of falls were left blank.
- The Actions Taken section showed (after the fall), "Fall sign placed on door," which was eight days after the patient was identified as a high fall risk.
- The care plan was not updated per the documentation.
- The 03/11/15 fall risk score was "17;" however, the care plan was not revised with interventions to prevent further falls.
- On 03/15/15, at 9:15 AM, the patient was found on the floor again.
- The Actions Taken section showed, "Bed alarm placement."

Observation and concurrent interviews on 04/01/15 at 2:30 PM, showed the following:
- Staff LL, RN, stated that Patient #31 had a bed alarm.
- The bed alarm was unhooked and the main device (this type of alarm consisted of the mechanical, sound producing box, a pressure sensitive pad that goes under the patient, and cords to the box and outlet-when the patient raised, or attempted to leave the bed, the alarm sounded) was across the room on top of the medication cabinet.
- Staff LL was unaware the patient's alarm had not been hooked up, and stated that she last saw the alarm connected at about 7:00 AM that morning, or seven hours earlier.
- Staff LL did not know how the alarm got disconnected.
- Staff MM, CNA, stated that she did not disconnect the alarm and did not know the alarm was disconnected. Staff MM stated that she knew Patient #31 had a bed alarm over the prior weekend, but she did not get a patient report before she started her shift this morning which would have updated her on the patient's bed alarm status. Staff MM stated that she did not read the care plans.

During an interview on 04/02/15 at 9:20 AM, Staff OO, Chief Clinical Officer, stated that she expected the RN's to be accountable for making sure fall interventions were in place at all times, and all documentation was complete and appropriate.

Based on observation, interview, record review and policy review, the facility failed to initiate a fall prevention care plan, in a timely manner, for one (#5) patient, and revise and/or utilize individualized interventions to prevent falls, per policy, for two (#5 and #31) of two patients reviewed with falls. These failures had the potential to place all patients admitted to the facility at risk for repeated falls. The facility census was 46.

Findings included:

1. Record review of the facility's policies titled, "Assessment/Re-Assessment-Interdisciplinary Patient," dated 02/2014 and, "Falls Prevention," dated 08/2014, directed the Registered Nurse (RN) to do the following:
- The admission assessment data is a primary source for the RN to determine and prioritize nursing care needs specific to the patient. A Patient Plan of Care (care plan) is developed by the RN based on identified problems and patient specific needs.
- The admitting RN will screen each patient to identify fall risk.
- All patients will have standardized fall prevention interventions.
- A fall risk score of ten or above indicates the patient is a high risk for falls. Additional interventions will be added to their care plan to prevent falls. These may include a "risk for falls" sign/device (falling star, falling leaves, bracelets) to communicate the risk to all caregivers, bed alarms, floor mats, rehabilitation evaluation, and use of low beds (a bed that can be lowered, more than the average bed, to attempt to prevent fall injuries).
- When a fall occurs, regardless of the risk score, additional interventions will be added.

2. Record review of Patient #5's History and Physical (H & P) dated 02/10/15, showed the patient was admitted on 02/09/15 with diagnoses of traumatic brain injury (an external force causing brain injury/damage), multiple fractures, and he had a circular, surgical steel device screwed to his head called a halo (this device could cause poor balance related to the extra weight on the head).

Record review of Patient #5's fall risk assessment dated 02/09/15, showed a score of "10," or a high risk for falls.

Record review of After-Fall Assessment Worksheet documentation showed the patient fell on 02/10/15, 02/19/15, 02/20/15, 02/22/15, 02/23/15, and 03/19/15. Decision-making areas regarding the addition of interventions to the care plan were inconsistently completed.

Record review of the patient's care plan on 03/31/15, showed the following:
- Potential for injury related to history of previous falls and impaired mobility was initiated on 02/20/15, or ten days after his first fall on 02/10/15.
- The goal stated he would have no falls through 04/05/15.
- Interventions included providing adequate light, use of a high/low bed with floor mats, and implement safety measures.
- On 02/23/15, interventions of implement precautions related to sensory deficits, and staff will monitor with continuous observation during times of increasing activity, thrashing, and flailing in bed were added. The goal did not change even though the patient had fallen four times since the goal was initiated.
- No further interventions and/or goals had been revised as of this review, even though the patient fell again after the 02/23/15 revision.

Observation and concurrent interview on 03/31/15 at 10:50 AM showed there were no floor mats beside the patient's bed. Staff P, Certified Nurse Assistant (CNA), stated that she did not put the floor mats beside the bed as long as she, or someone else was in the room with the patient (contrary to the care plan). Staff P stated that the patient was typically very active/spastic, swinging his legs and arms, flinging himself on the floor.

During an interview on 03/31/15 at 1:27 PM, Staff X, RN Supervisor stated that Patient #5 fell out of bed on 03/19/15 in spite of having a CNA in the room at the time.

During an interview on 03/31/15 at 4:20 PM, Staff R, Director of Quality, confirmed that staff failed to update the care plan with appropriate interventions.

3. Record review of Patient #31's H & P dated 02/21/15, showed the patient was admitted on 02/20/15 with a diagnosis of muscle weakness.

During an interview on 04/01/15 at 9:10 AM, Patient #31 stated that she had fallen out of the bed, to her knees, several days prior.

Record review of Patient #31's nursing admission assessment, dated 02/20/15, showed the following:
- The patient had lower extremity edema (swelling which could cause difficulty standing/walking) and weakness.
- The patient took high risk medications (pain and antianxiety medications that could cause drowsiness and dizziness, contributing to falls).
- The patient had an unstable balance.
- The patient forgot instructions.
- The patient's fall risk score was "12."

Record review of the Notice of Change in Condition documentation showed the following:
- On 02/28/15, the patient was found sitting on the floor next to her bed.
- On 03/15/15, the patient was found on a mat on the floor next to her bed.
- Patient #31 had a right knee abrasion (scrape) due to the fall on 03/15/15.

Record review of the patient's care plan dated 02/20/15, showed the following:
- Potential for injury related to age, impaired physical mobility, and unfamiliar surroundings.
- A goal that she would be free of falls through 04/12/15.
- No interventions until 03/16/15. Then, only one for a bed alarm.

Record review of After-Fall Assessments for Patient #31 showed the following:
- On 02/28/15, a falling star sign was placed on the patient's door after the patient's fall, or eight days after the patient was identified as a high fall risk.
- The care plan was not updated per the documentation.
- The 03/11/15 fall risk score was "17;" however, the care plan was not revised with interventions to prevent further falls.

Observation and concurrent interviews on 04/01/15 at 2:30 PM, showed Patient #31's bed alarm was unhooked and the main device (this type of alarm consisted of the mechanical, sound producing box, a pressure sensitive pad that goes under the patient, and cords to the box and outlet-when the patient raised, or attempted to leave the bed, the alarm sounded) was across the room on top of the medication cabinet.
- Staff LL was unaware the patient's alarm had not been hooked up, and stated that she last saw the alarm connected at about 7:00 AM that morning, or seven hours earlier.
- Staff MM, CNA, stated that she did not disconnect the alarm and did not know the alarm was disconnected. Staff MM stated that she did not read the care plans.

During an interview on 04/02/15 at 9:20 AM, Staff OO, Chief Clinical Officer, stated that she expected the RN's to be accountable for making sure fall interventions were in place at all times, and all care plan documentation was complete and appropriate.

Based on interview and record review the facility failed to ensure the therapeutic diet manual was available to all staff for use as a diet reference. This deficient practice had the potential to permit staff to serve patients unapproved therapeutic diets. The facility census was 46.

Findings included:

1. Record review of a printed copy of the facility Diet Manual showed the Medical Executive Committee (MEC) had approved the diet manual as a therapeutic diet reference on 11/13/12.

2. During an interview on 03/30/15 at 1:58 PM, Staff A, Director of Dietary, stated that the facility diet manual was on-line and was accessible by every nursing staff through the facility intranet at each nurse's station.

During an interview on 04/01/15 at 12:25 PM, Staff G, Registered Nurse (RN), third floor, stated that she thought the facility diet manual was in some folders somewhere on the unit however, she did not know exactly where the diet manual folders were located.

During an interview on 04/01/15 at 3:50 PM, Staff CC, Licensed Practical Nurse (LPN), second floor, stated that he was not aware that the facility had a diet manual.

During an interview on 04/01/15 at 3:57 PM, Staff HH, RN, second floor, stated that he ordered patient diets on the facility computer system and did not know if the facility had a diet manual.

During an interview on 04/01/15 at 3:58 PM, Staff RR, LPN and Staff SS, LPN, both stated that they had never seen a diet manual in the facility.

Based on observation, interview and record review the facility failed to ensure the Rehabilitation department's one of one cold pack machine was maintained at a safe temperature and the one of one hot pack
machine and one of one cold pack machines were maintained per manufactures guidelines. The facility also failed to ensure the Dietary department maintained disposable emergency supplies (foam dishes, trays, cups, lids, plastic eating utensils) that could be used in patient meal service, in a manner that maintained safety and quality.
These deficient practices had the potential to place Rehabilitation patients at risk for skin damage due to cold packs that were kept at inappropriately low temperatures and lack of cleaning of both cold and hot pack machines to maintain machine reliability. These deficient practices also had the potential to permit patients to receive foods exposed to cross contaminants on unsafely stored disposable emergency supplies. The facility census was 46.

Finding included:

1. Record review of the facility's policy titled, "Clinical Practice Guidelines," dated 05/27/14 showed directives for staff to clean the hydrocollator (metal box, filled with water, used to heat packs, used for pain relief) machine every two weeks. Staff should:
- Drain the tank.
- Clean the inside of the tanks using a mild disinfectant and soap. Do not use abrasives.
- Clean the outside of the tank with a damp cloth and polish with a dry, soft cloth.
- New packs should be soaked overnight before use.

2. Record review of the hydrocollator machine cleaning log for the last six months showed that the machine was cleaned three out of twelve times per policy guidelines.

During an interview on 04/01/15 at 9:00 AM Staff II, Rehabilitation technician, stated that he only cleaned the machine when it was in use. He stated that he did not have a cleaning schedule.

During an interview on 04/02/15 at 9:45 AM, Staff PP, Director of Rehabilitation unit, stated that she was unaware of cleaning schedule for the hydrocollator.

3. Record review of the facility's policy titled, "Clinical Practice Guidelines," dated 05/27/14 showed directives for staff to:
- Clean the cold pack machine (a metal box used to store packs cooled for patient pain relief) when frost builds up in the machine.
- The machine should be defrosted and the tank wiped dry with a clean towel or cloth.
- The temperature of the cold pack, when chilled should be approximately 10 F (Fahrenheit - a unit of measure) to 21 F.

4. Observation and concurrent interview on 04/01/15 at 9:20 AM showed cold pack machine temperature logs of 0 F for the months of 10/2014 to 02/2015. Temperature logs for 03/2015 and 04/2015 showed temperature logs ranging from 16 F to 18 F. Staff II stated that he did not know how to adjust the temperature and that he did not have a policy and procedure on the machine.

During an interview on 04/02/15 at 10:00 AM, Staff PP, stated that patients were at risk for skin damage, and possible skin burn when the cold pack was too cold. Staff PP stated that there was no patient log to track use of the cold packs.

5. Record review of the "Missouri Food Code for Food Establishments of the State of Missouri," Chapter 4-903.11 (A) (1) and (2), dated 06/03/13, showed directives for Dietary staff to store single use articles (foam dishes) and utensils (plastic knives, forks, spoons) in clean, dry locations, not exposed to splash, dust, or other contamination and Chapter 4-903.11 (C) showed directives for staff to store single use articles in the original protective package or by using other means that afford protection from contamination until used.

6. Observation on 03/30/15 from 3:42 PM through 4:05 PM and again on 04/02/15 from 8:45 AM through 9:50 AM in the kitchen showed the following:
- Two sleeves of hinged foam food containers stored with the plastic protective sleeves torn open to air (stored in the room below the staircase);
- A full case of plastic spoons stored with the plastic protective liner opened to air on a lower shelf in the paper goods storeroom;
- A sleeve of foam cups that had fallen on the floor with the plastic protective sleeve torn open to air;
- Disposable containers (reported to be used for kidney dialysis patient snacks) stored unprotected on a shelf in the paper good storeroom; and
- An unknown quantity of plastic coffee cup lids stored in a soiled box in the paper goods store room.

During an interview on 03/30/15, Staff A, Director of Dietary stated that the emergency supplies (foam dishes and plastic utensils) should be stored protected against cross contamination and the hinged container; plastic spoons; foam cups; disposable containers and plastic coffee cup lids were not stored appropriately.


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Based on observation, interview, and policy review, the facility failed to ensure that:
- Registered Respiratory Therapy (RRT) staff followed their policy for hand hygiene (to cleanse hands with hand sanitizer or soap and water) for three patients (#13, #14 and #12) out of six patients observed during dressing change.
- RRT staff maintained dressing care supplies in a clean area that controlled and reduced the risk of contamination from non clean items for three patients (#13, #14, and #12) of six patients during wound care.
- Dietary staff cleaned kitchen equipment used in patient meal service;
- Dietary staff cleaned floors and maintained a sanitary environment for patient food preparation and service;
- Dietary staff covered three of three thirty gallon trash receptacles and removed accumulated trash from the food production and service areas;
- Dietary staff maintained three of three food wiping cloths submersed in sanitizing solutions between uses;
- The Director of Dietary consistently wore effective hair restraint while in the kitchen;
- Dietary staff stored a case of frozen cookie dough to protect against cross contamination; and
- Dietary staff washed dishes, eating utensils and trays, used in patient meal service, in a dish washing machine with verifiable and appropriate water temperatures.
These failed practices during dressing change increased the risk of infections and cross contamination and placed all patients, visitors, and personnel at increased risk for hospital acquired infections (HAI) and communicable diseases and deficient practices in the Dietary department had the potential to permit cross contamination of foods, dishes and utensils used in patient meal service and cause food borne illness. The census was 46.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene", revised 08/2012, showed directive for staff to perform hand hygiene:
- After situations during which microbial contamination of the hands is likely to occur (i.e. contact with potentially contaminated environmental surfaces);
- After covering a cough or a sneeze;
- Before putting on and after removal of gloves.

Record review of the facility's policy titled, "Tracheostomy tube cannula and stoma care (the surgical formation of an opening into the windpipe through the neck especially to allow the passage of air)", revised 10/03/14, showed directive for staff to place equipment and supplies on a clean table or stand near the patient's bed.

2. Observation on 03/31/15 at 8:45 AM showed Staff V, RRT, changed dressing for Patient #13's tracheostomy. Staff V put on gloves and placed sterile dressing supplies on patient's soiled bed linen. Staff V touched his nose with his gloved hands. Staff V with same gloved hands removed soiled tracheostomy dressing. Staff V changed gloves, failed to perform hand hygiene, put on new gloves and applied new dressing to tracheostomy site.

During an interview on 03/31/15 at 9:05 AM, Staff V stated that he should not have touched his nose with his gloved hand. Staff V stated that he should have provided a clean area for his dressing supplies, because patients sometimes cough during dressing change. Staff V stated that he should have performed hand hygiene after glove removal.

3. Observation and concurrent interview on 03/31/15 at 9:30 AM showed Staff W, RRT, changed dressing for Patient #14's tracheostomy. Staff W put on gloves and placed sterile dressing supplies on patient's soiled bed linen. Staff W with gloved hands removed soiled tracheostomy dressing. Staff W changed gloves, failed to perform hand hygiene, put on new gloves and applied new dressing to tracheostomy site. Staff W stated that she did not perform hand hygiene after her glove change because she didn't think she needed to because she was providing care for the same patient.

4. Observation and concurrent interview on 03/31/15 at 11:00 AM showed Staff U, RRT, changed dressing for Patient #12's tracheostomy. Staff U put on gloves and placed sterile dressing supplies on patient's soiled bed linen. Staff U with gloved hands removed soiled tracheostomy dressing. Staff U changed gloves, failed to perform hand hygiene, put on new gloves and applied new dressing to tracheostomy site. Staff U stated that he did not perform hand hygiene after his glove change because he didn't think he needed to because he was taught that as long as he was with the same patient he didn't need to perform hand hygiene.

During an interview with Staff TT, Director of Respiratory Therapy, on 03/31/15 at 11:30 AM, Staff TT stated that staff needed to perform hand hygiene after gloves were removed and before putting on new gloves.

During an interview on 04/02/15 at 11:00 AM Staff M, Registered Nurse (RN), Clinical Nurse Specialist (CNS), Infection Control Officer (ICO), stated that she would expect hand hygiene to be performed after glove change. Staff M stated that staff are to maintain a clean area during dressing change procedure.

5. Record review of the "Missouri Food Code for the Food Establishments of the State of Missouri," (MO Food Code) Chapter 4-601.11(A), dated 06/03/13, showed directives for Dietary staff to ensure food contact surfaces of equipment were clean to sight and touch.

6. Observation on 03/30/15 at 4:05 PM in the salad preparation area showed staff failed to clean and maintain a table mounted can opener, sticky with food spills and debris on the holster and on the plate holding the can opener to the table.

Observation on 03/30/15 at 4:07 PM in the cook's area showed staff failed to clean and maintain a second table mounted can opener with multiple slivers of metal can shavings imbedded in blackened food debris in gears behind the blade.

During an interview on 03/30/15 at 4:07 PM, Staff A, Director of Dietary stated that staff should be washing the can openers daily and the holsters and the mounting plates holding the can openers to the table had not been routinely washed.

7. Observation and concurrent interview on 04/01/15 at 9:20 AM in the cook's area showed Staff FF, Cook, cleaning a food debris spattered pot and pan rack. Staff FF stated that she had cleaned the shelves of the pot and pan rack, a few months ago but, had never cleaned the under sides of the shelves; wheels or rubber wheel bumpers that were covered with dried food drips and food crumbs imbedded in debris.

8. Record review of the "MO Food Code," Chapter 4-601.11(C) dated 06/03/13, showed the directive for Dietary staff to ensure non-food contact surfaces in the kitchen were free of accumulated dust, dirt, food residue and other debris.

9. Observation on 03/30/15 from 3:42 PM through 4:05 PM in the facility kitchen showed staff failed to clean and maintain the following:
- A soiled walk-in refrigerator floor, spattered with dried, dark red circles of unknown debris, under a shelf where staff thawed meat;
- A very wet walk-in refrigerator floor with an approximate one quarter inch deep pool of water from an unknown source;
- Two heavily soiled canned food racks (nine shelves each) with rails thick with dust and unknown debris accumulated where the rims of the cans rested; and
- A heavily soiled floor in the dry food store room with the perimeter of the floor lined with blackened soil and debris.

During an interview on 03/30/15 at 4:08 PM, Staff A stated the following:
- The dark red circles of dried debris in the walk-in were probably blood from the thawing meat;
- The one quarter inch deep pool of water in the other walk-in was due to moisture from the adjacent walk-in in freezer;
- The two can racks in the dry food store room needed to be cleaned; and
- The last time the kitchen was "deep cleaned" was about a year ago.

10. Observation on 04/02/15 at approximately 9:30 AM in the kitchen near the patient tray assembly line showed staff failed to clean a heavily soiled (appeared fuzzy) condenser guard over the wall refrigeration units.

During an interview on 04/02/15 at approximately 9:30 AM Staff A confirmed the refrigerator condenser guard needed to be cleaned.

11. Record review of the "MO Food Code," dated 06/03/13, showed the following directives for Dietary staff:
- Chapter 5-501.113 showed staff should cover receptacles and waste handling units (trash cans) with tight fitting lids.
- Chapter 5-501.116 showed staff should frequently clean trash receptacles to prevent buildup of soil or debris that may attract insects or rodents. and
- Chapter 5-502.11 showed staff should frequently remove filled trash receptacles (from the kitchen) to minimize objectionable odors and conditions that may attract insects and rodents.

12. Observation on 03/30/15 from 3:42 PM through 4:05 PM in the kitchen showed staff maintained three uncovered, soiled (exterior surfaces and handles), partially filled thirty gallon trash cans in various areas of the kitchen (cook's area, salad preparation area, dish washing area).

Observation on 03/30/15 at 3:45 PM showed staff stored two large approximate four foot by four foot by four foot soiled, food spattered trash receptacles adjacent to a preparation table where staff wrapped sliced bread and less than five feet from the tray assembly line.

During an interview on 03/30/15 at 3:45 PM, Staff A stated the following:
- Staff dumped trash from the thirty gallon trash cans into one of the large trash receptacles, three or four times a day.
- Staff placed cardboard boxes into the other large trash receptacle. and
- When the two large receptacles were filled, (two to three times a day) staff moved the large receptacles to the outside dumpsters.

13. Record review of the " MO Food Code," Chapter 3-304.14 dated 06/03/13, showed the directive for Dietary staff to maintain food wiping cloths submersed in a chemical sanitizer solution between uses.

14. Observation on 03/30/15 from 3:42 PM through 4:05 PM and again on 04/01/15 at 9:30 AM showed Dietary staff stored used, wet, food wiping cloths on counters and on a three tiered cart.

During an interview on 04/01/15 at 9:30 AM, Staff FF, Cook, stated that the used, wet food wiping cloths were usually discarded after use but she had neglected to discard the used cloth on the cart.

15. Record review of the "MO Food Code," Chapter 2-402.11 dated 06/03/13, showed the directive that Dietary staff should wear effective hair restraints to prevent hair from contacting uncovered food, clean equipment and utensils.

16. Observations on 03/30/15 from 3:42 PM through 4:05 PM; on 04/01/15 from 8:45 AM through 10:05 AM and on 04/02/15 from 8:45 AM through 9:50 AM showed Staff A, Director of Dietary wore a hair restraint that only partially covered her hair, exposing multiple hairs across her forehead.

17. Record review of the "MO Food Code," Chapter 3-305.11 dated 06/03/13, showed the directive for Dietary staff to store foods protected against cross contamination and not exposed to splash, dust, or other contamination.

18. Observation on 03/30/15 at 3:55 PM in the walk-in freezer showed staff stored an opened case of cookie dough on a lower shelf with the plastic liner opened to air.

During an interview on 03/30/15 at 3:55 PM, Staff A, confirmed the case of cookie dough was opened; the cookies were exposed to cross contamination and staff should have covered the cookies with the plastic case liner.

19. Record review of the "MO Food Code," Chapter 4-203.12 (B) dated 06/03/13, showed directives for the Dietary staff to ensure water temperature measuring devices were accurate to plus or minus three degrees Fahrenheit (F) of the intended range for use and Chapter 4-501.112 showed directive for staff to ensure ware washing equipment (dish washer), with hot water sanitization, reached 180 degrees F.

20. Observation and concurrent interview on 04/01/15 from 9:55 AM through 10:02 AM in the dish washing area showed the following:
- The manufacturer's water temperature requirement, stamped on a metal plate attached to the dish washer, was 180 degrees F for rinsing.
- Staff GG, Kitchen supervisor, operated the dishwasher and the rinse temperature reached approximately 176 degrees F.
- The second attempt showed the rinse water was 178 degrees F. and
- Staff GG confirmed the rinse water temperatures did not reach the manufacturer's required levels and the low temperatures may be due to a problem with the gauges.

Observation and concurrent interview on 04/01/15 at 11:52 AM in the dish washing area showed the following:
- Staff GG operated the dish washer.
- The first attempt showed the rinse water reached only 140 degrees F.
- The second attempt showed the rinse water reached only 140 degrees F.
- The third attempt showed the rinse water fell to 138 only degrees F. and
Staff GG confirmed the dishwasher was not operating correctly and the water temperatures for the rinse cycle were below the required level. Staff GG stated that the dishwasher temperature gauges needed to be replaced.

During an interview on 04/02/15 at 9:58 AM, Staff M, Infection Control (IC) Nurse and Clinical Nurse Specialist confirmed the following:
- The IC nurse was responsible for monitoring infection control practices in the entire facility including the Dietary department.
- The IC nurse participated in environmental rounds in the Dietary department and identified issues including caulking in some locations needed to be repaired and that tube feeding products needed to be relocated to another department but, no examples of soiled equipment, soiled floors, inappropriate food storage, dishwasher problems or unrestrained hair were identified. and
- She expected the Dietary department to operate in a safe, sanitary manner by following recognized food sanitation and safety requirements.


16215

Based on interview and record review, the facility failed to ensure that the discharge medication list was reconciled (compared) to the pre-admission medications for one current patient (#32) and two discharged patients (#9 and #10) of three patient records reviewed for discharge instructions to home. The facility failed to include food/drug interactions on the list and to write the medication directions in layman's terms (understandable to the average person) as per its discharge planning policy. These failures increased the potential for omission, duplication, incorrect dosage, and adverse interaction in the medication regimen (plan) for all patients discharged to home. The facility census was 46.

Findings included:

1. Review of the Agency for Healthcare Research and Quality (AHRQ) patient safety primer on medication reconciliation retrieved online on 04/03/15 showed:
- Medication reconciliation refers to the process of avoiding inadvertent inconsistencies across transitions in care by reviewing the patient's complete medication regimen at the time of admission, transfer, and discharge and comparing it with the regimen being considered for the new setting of care.
- The new medication regimen prescribed at the time of discharge may inadvertently omit needed medications, unnecessarily duplicate existing therapies, or contain incorrect dosages.
- These discrepancies place patients at risk for adverse drug events (ADEs), which have been shown to be one of the most common types of adverse events after hospital discharge.

Record review of the facility policy titled, "Discharge Planning," revised 03/2012, showed the staff directive to provide the patient and family/caregiver with the discharge instruction sheet on treatment and medications (including food/drug interactions) and that all written instructions should be in layman's terms.

2. During an interview on 04/01/15 at 9:00 AM, Staff CC, LPN, stated that the case manager had given him the discharge paperwork for current Patient #32 who was going home that day. The paperwork included the electronic discharge medication list (in medical terms) and a blank Discharge Medications form. He had been trained that the form was to be filled out if the patient or caregiver needed a dosing schedule to use at home. He did not plan on filling it out for Patient #32.

3. Record review of the discharge medication lists provided for current Patient #32 and discharged Patients #9, #10 showed:
- The lists were printed from the electronic medication administration record.
- There was no indication on the lists that the discharge medications had been compared to the pre-admission medications.
- There was no indication that food/drug interactions had been considered.
- The medications on the lists were in medical terms (for example, magnesium oxide 800 mg PO q12h, which in layman's terms would read: take 800 mg of magnesium oxide by mouth every 12 hours).

During an interview on 04/01/15 at 11:15 AM, Staff L, Director of Pharmacy, stated that comparison of pre-admission medications with medications ordered by the admitting physician was performed upon admission for each patient. She was unaware the pre-admission medications were not included on the discharge medication list with clear indication what pre-admission medication prescriptions were to be continued, changed, or discontinued. She stated that this comparison should be performed for patient safety at home.

4. Record review of the Discharge Medications form for Patient #10 showed:
- The form had columns for Drug Name, Dosage, Times to be Taken, Purpose, and Special Instructions.
- The discharging physician had written "See scripts" in the Drug Name column and signed on the physician signature line at the bottom of the form.
- There were signature lines for the patient/family and nurse signatures at the bottom of the form.

During an interview on 04/01/15 at 12:30 PM, Staff KK, Case Manager, stated that she generated the electronic discharge medication list with a blank Discharge Medications form and gave them to the nurse discharging the patient. She stated that the nurse was to rewrite the list in layman's terms on the form to give to the patient.

Based on interview and record review, the facility failed to document that the home health agency (HHA) or skilled nursing facility (SNF) list for patient choice was presented to two current patients (#1 and #2) and one discharged patient (#9) whose discharge plans were reviewed. This failure increased the potential that patients discharged to HHA or SNF could not exercise their right to choose the post-acute provider. The facility census was 46.

Findings included:

1. Record review of the facility policy titled, "Post Discharge Referrals - Offering Choice," revised 08/2012, showed the following staff directives:
- Patients will be informed of their discharge options and be offered choices in selecting their post-acute provider.
- The facility will provide each patient with provider options of the needed service in the geographic area.
- The facility will maintain a list of HHAs serving the area in which the hospital's patients reside.
- The facility will provide SNF lists by geographic area and services provided.
- Patients will be offered choice and documentation of choice is accomplished utilizing the Patient Choice Form or documented in the medical record.

Record review of the Patient Choice Form showed the following content:
- I have been provided with list of providers of (write in service).
- This list is for the geographic area requested or appropriate area required.
- My choice of providers is indicated below (write in).
- Date and signature lines for the patient and the case manager were at the bottom of the form.

2. Record review of the discharge planning documentation in the medical records for current Patients #1 and Patient #2 showed:
- Planned discharge to SNF;
- No documentation that the SNF list was presented to the patients; and
- No completed and signed Patient Choice Forms.

3. Record review of the discharge planning documentation in the medical record for discharged Patient #9 showed:
- Discharge to home with HHA;
- No documentation that the HHA list was presented to the patient; and
- No completed and signed Patient Choice Form.

During an interview on 03/31/15 at approximately 10:00 AM, Staff H, Director of Case Management, stated that there was no documentation in the medical records for Patients #1, #2, and #9 that the case manager had given the HHA or SNF list to the patients to choose a provider. He stated that case manager documentation does not include this in any patient's discharge plan.

During an interview on 04/01/15 at 12:30 PM, Staff KK, Case Manager, stated that she does not document in any patient's record that she has given the HHA or SNF list to the patient to choose a provider. She stated that she was unaware of the Patient Choice Form.