HospitalInspections.org

Based on observation, interview and record review facility staff failed to ensure patients and visitors were provided full disclosure of video monitoring and the possibility of video recording by seven cameras located at entrances, hallways and public areas of the building. The facility census was 18 inpatients.

Findings included:

1. Record review of the facility admission packet information sheet (undated) titled, Consent for Treatment/Transport, Authorization for Release of Information, and Payment Acknowledgment of Receipt Release of Liability Notice, paragraph titled Authorization to Release Information directed in part the facility was granted permission to obtain photographs, videos and/or movies for educational purposes or for the patient's medical record as deemed necessary by the patient's physician.

2. Observation on 01/04/10 at 2:25 p.m. in the hallway outside the Health Information Management Offices revealed staff maintained a ceiling mounted video camera over an exterior entry positioned to provide full view of the hallway.

Observation on 01/05/10 from 11:45 a.m. through 12:00 noon at the Nurses Station revealed staff maintained two ceiling mounted video cameras positioned to provide full view of the area around the unit nurses station.

3. During an interview on 01/05/10 at 2:00 p.m. the Chief Clinical Officer (CCO), Staff K stated the following:
-The facility used seven video cameras to monitor various locations.
-The facility video monitored building exits, the medication rooms, the area around the nurses desk and the lobby.
-The video monitoring by those cameras could be viewed on any computer monitor after entering specific log on by the Chief Executive Officer, the CCO and the Information Technology staff person (who maintained the system).
-The video monitoring was recorded from all the cameras and held on the computer hard drive for seven days.
-After seven days the hard drive purged the oldest data.
-Any images could be recorded onto a disc from a specific date and time (within the last seven days) and be provided to anyone who required the information.
-No specific signage was posted throughout the facility informing patient, visitors or the general public of the video monitoring and/or possibility of being video recorded.

Based on Missouri State Statute review, personnel record review and interview the facility failed to ensure individuals listed on the Employee Disqualification List (EDL, a listing of persons who had abused or neglected patients under their care) were not employed by the facility. Personnel records reviewed of thirteen facility staff (Staff L, M, N, O, A, P, S, T, U, V, W, X, Y) and sixty-one contracted staff in eleven different departments revealed the facility failed to compare the names of staff on a periodic basis against the EDL. The facility census was 18 patients.

Findings included:

1. Review of the Missouri State Statute RSMO 2003 Section 660.315 directed facilities licensed under Chapter 197 (hospitals) complete not only pre-employment EDL checks but also periodic checks of all existing staff against the quarterly updated EDL to ensure no current staff had been recently added to the EDL (The quarterly updated EDLs are available on the Missouri Department of Health and Senior Services web site).

2. Record review of facility Staff L's personnel file revealed Staff L had been employed in the facility since 06/11/07, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

3. Record review of Staff M's personnel file revealed Staff M had been employed in the facility since 08/28/06, had not had any verification that he/she was not on the EDL on hire and had not had periodic verification that he/she was not on the EDL.

4. Record review of Staff N's personnel record revealed Staff N had been employed in the facility since 02/06/07, had not had an EDL verification done on hire and had not had any periodic verifications that he/she was not on the EDL.

5. Record review of Staff O's personnel record revealed Staff O had been employed in the facility since 10/29/07 had not had an EDL verification done on hire and had not had any periodic verification that he/she was not on the EDL.

6. Record review of facility Staff A's personnel file revealed Staff A had been employed in the facility since 01/15/07, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

7. Record review of facility Staff P's personnel file revealed Staff P had been employed in the facility since 02/06/06, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

8. Record review of facility Staff S's personnel file revealed Staff S had been employed in the facility since 05/20/08, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

9. Record review of facility Staff T's personnel file revealed Staff T had been employed in the facility since 09/23/09, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

10. Record review of facility Staff U's personnel file revealed Staff U had been employed in the facility since 07/07/08, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

11. Record review of facility Staff V's personnel file revealed Staff V had been employed in the facility since 07/02/09, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

12. Record review of facility Staff W's personnel file revealed Staff W had been employed in the facility since 12/09/08, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

13. Record review of facility Staff X's personnel file revealed Staff X had been employed in the facility since 03/03/09, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

14. Record review of facility Staff Y's personnel file revealed Staff Y had been employed in the facility since 07/15/08, had an EDL check done on hire and had not had periodic verification that he/she was not on the EDL since that time.

15. Record review of faxed documents showing EDL checks done on contracted staff revealed some of the EDL checks were done during survey (dated 01/05/10 and 01/06/10) and others were done on the contractor's date of hire with their parent company.

16. During an interview on 01/06/07 at 11:10 a.m. the Chief Clinical Officer (CCO), Staff K stated the facility practice had been to check new hires against the EDL but, not to perform periodic checks of all staff against the EDL. The CCO further stated the contracted staff were not checked against the EDL because the facility felt it was the responsibility of the parent company to verify those staff were not on the EDL.


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17. Staff B, Human Resources Director said during an interview on 01/04/09 at 4:15 p.m. that EDL checks are done on hire for all facility employees, but are not done periodically.



19957

Based on record review and interview the facility failed to insure all privileges actually practiced by physicians are requested by the physicians and approved by the medical executive committee and governing body for three of five physicians reviewed (BB,CC,DD). The facility failed to insure that all physicians were credentialed every two years for one of five physicians reviewed (BB). This affects all patients in the care of these practicing physicians in a census of 18.
Findings included:
1. During an interview on 01/05/10 at 3:00 p.m. Staff K stated that the three physicians (BB, CC, DD) do perform duties included in the core privileges (as described in credentialling packet form) at the facility.
2. Review of the credentialing packets of five physicians was done on 01/05/10. Three of the physicians did not indicate a request for the core privileges in their specialty.
Review of the credentialing packets revealed a form specific to a specialty in medicine. On the first page of each form was an area for core privileges. The first choice required the physician to indicate if the core privileges were requested. The other three boxes were for the final determination of whether the request for core privileges had been recommended, not recommended, or recommended with modifications.
3. Physician BB had completed a privileges in general surgery form with the physician signature dated 05/03/06 (more than two years). The choice for core privileges requested remained blank. The definition of core privileges for this specialty included to admit patients, diagnose, consult and provide pre-operative , intra-operative and post operative care for patients. The second page of the form indicated check marks under the requested column for special procedures for nine special procedures. The recommended and not recommended columns remained blank.
The department chair signed the privileges form on 8/2/06. The form indicated that this signature meant the privileges had been reviewed and recommended action on the privileges as noted above.
4. Physician #CC had requested privileges in two specialties. The family medicine privileges were signed by the physician on 09/02/08 and the box for core privileges requested remained blank. The boxes for whether the privileges had been recommended or not recommended remained blank. The core privileges were defined in part as admission of patients, evaluation of patients and diagnosis. The medical executive representative signed the form on 09/11/08 and the governing body signed the form on 01/05/09.
Physician CC also requested privileges in wound care, which the physician signed on 09/02/08. The box for core privileges requested was blank as were the boxes for recommended or not recommended. The privileges for the core privileges were in part defined as evaluation, diagnosis and to provide treatment. There were three special procedures marked as requested in a separate area of the form.
The medical executive committee signed the form on 09/11/08 and governing board signed the form on 1/5/09. Both signature lines were preceded by language that stated these entities recommended action on the privileges as noted above.
5. Physician DD requested privileges in internal medicine and signed this form on 04/28/08. For the section of privileges included in the core are in part; admission of patients, diagnosis and consultation. The requested, recommended and not recommended sections remain blank. The representative for the Medical Executive committee signed the form on 07/17/08 and the Governing body representative signed the form on 08/21/08. Both sections contain that they have reviewed the requested clinical privileges and supportive documentation and recommend action on the privileges as noted above.

Based on collaborative agreement review, record review, interview and observation the facility failed to ensure the sponsoring physician reviewed and/or evaluated the clinical work for one of one (Staff EE) advanced practice nurse and the facility failed to post or display a disclosure statement informing patients they may be seen by an advanced practice nurse as required in the collaborative agreement. Two records with consultations completed by an advanced practice nurse were reviewed. The facility census was 18.
Findings included:
Review of the collaborative practice agreement dated 10/28/08 showed Physician FF signed an agreement with Advanced Practice Nurse (APN) Staff EE. Review of section 4.2 showed, "APN shall submit documentation of the APN's prescribing practices to the Physician within fourteen (14) days. The documentation shall include but not be limited to, a random sample review by the Physician of at least twenty percent (20%) of the charts and medications prescribed. Physician shall review the work, records, and practice of health care delivered pursuant to this Agreement at least once every two (2) weeks, which review shall be documented by Physician."
Review of section 6.7 showed, "There shall be posted in every office where APN is authorized to prescribe in collaboration with Physician, a prominently displayed disclosure statement informing patients that they may be seen by an APN and have the right to see the Physician."
Review of the history and physical for current Patient #9 showed the patient entered the facility 12/22/09 following a stay at an acute care facility for injuries suffered in a motor vehicle accident. The patient entered this facility for continued rehabilitation and medical management of multiple injuries sustained in the accident. The patent's physician ordered a consult for Physician FF to continue to follow the patient for management of injuries.
Review on 01/05/10 of a consultation record dated 12/23/09 showed APN Staff EE saw Patient #9 and discussed the plan of care with the patient. The consultation note is not signed by the APN or by the collaborating physician Staff FF.
Review of the history and physical for discharged Patient #22 showed the patient entered the facility 8/26/09 for antibiotic therapy and wound care.
Review on 01/06/10 of a consultation record dated 09/09/09 showed APN Staff EE saw Patient #22 and discussed the plan of care with the patient. The consultation note is signed by the APN and by the collaborating physician Staff FF but the signatures have no date or time. It is unknown when the sponsoring physician reviewed and approved of the consult performed by APN Staff EE.
Observation on 01/05/10 from 11:45 a.m. through 12:00 noon at the Nurses Station revealed no signage posted informing patients they may be seen by an advanced practice nurse as required in the collaborative agreement.
During an interview on 01/05/10 at 11:35 a.m. the Medical Staff secretary, Staff H said it is the facility's expectation that the sponsoring physician sign any consults done by an APN within 48 hours of the consult. Staff H said the facility does not have a written policy regarding this. Staff H said by signing the consults, the collaborating physician is showing his/her review of the work done by the APN. Staff H said the facility does not have any additional way to monitor if the collaborating physician is reviewing and approving of the work completed by the APN.

Based on policy review, record review and interview the facility failed to obtain physician's orders that contained all necessary information to administer medication for one patient (#20). The facility census was 18.
Findings Included:
Review of facility policy PCS-05-08, Prescribing/Ordering/Transcribing/Verification/Clarification of Orders showed in part, "Pharmacy will not fill medication orders that are illegible, incomplete or questionable until the order has been clarified. All written orders, including Protocols and Preprinted Forms must be signed by a licensed practitioner who has been granted prescribing authority by facility prior to pharmacy processing."
Review of the physician orders for current Patient #20 dated 12/14/09 at 2:20 p.m. showed an order to d/c (discontinue) Cefepine (an antibiotic) and d/c Ciprofloxacin (an antibiotic). There is no signature on the order. It is unknown what physician ordered the medication.
During an interview on 01/06/10 at 8:55 a.m. the Director of Pharmacy, Staff J said there is no physician's name on the order for Patient #20 and the director said the order is not a telephone order. The director said he/she did not know how the order was filled by the pharmacy without a physician's name. The director said the order should not have been filled by the pharmacy. The director said, "It just got missed." The director said he/she does not know which physician wrote the order. The director said he/she usually calls the nurse on the unit to have the order clarified by the physician.

Based on interview and record review facility staff failed to ensure all orders were dated, timed and authenticated in five (Patient #15, #3, #11, #12, #14) of twenty-three patient medical records reviewed for dated, timed and authenticated orders. The facility census was 18 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records (provided during the survey) in part, directed physicians to provide the following:
-A complete, legible medical record for each patient.
-All orders must be dated, timed and signed by the ordering physician or allied health practitioner responsible for the patient's care.

Record review of the facility policy titled Complete and Accurate Medical Records, #IM.34, reviewed 12/08, directed, in part, the following:
-A complete medical record will be maintained for every patient admitted to the facility.
-Each entry in the medical record is dated and timed by the provider at the time care is provided.

Record review of the facility policy titled Orders: Verbal and Written orders, #PC.16.5, revised 11/09, directed, in part, the following:
-Written orders must be authenticated and dated by the person responsible for the order.
-Each drug order shall include time and date of order.

2. Record review of current Patient #15's admission history and physical revealed staff admitted the patient on 12/15/09 with diagnoses including respiratory failure after tracheostomy tube placement (a two to three inch metal or plastic tube placed in a surgically created opening in the windpipe to keep the airway open) with ARDS {Acute Respiratory Distress Syndrome, a failure of the respiratory system with fluid buildup in the air sacs of the lung, subsequent breathing difficulty and oxygen deprivation to vital organs}, history of chronic obstructive pulmonary disease, multiple deep vein thrombosis {blood clots}, coronary artery disease {heart disease}, atrial fibrillation {irregular heart rhythm}, high blood pressure, encephalopathy/paralysis, clostridium difficile infection, anemia, urinary tract infection and sacral pressure ulcers.

Record review of the patient's physician's orders revealed an undated, untimed page one of a two page admission order set.

3. Record review of closed Patient #3's admission history and physical revealed staff admitted the patient on 08/20/09 for problems including respiratory failure after tracheostomy tube placement, history of aspiration pneumonia (pneumonia caused by oral or stomach contents into the lung), right sided MCA (a stroke cause by a problem involving the middle cerebral artery that supplies blood to a portion of the brain), diabetes treated with insulin and high blood pressure.

Record review of the patient's physician's orders revealed the following:
-An untimed restraint order dated 08/29/09.
-An untimed restraint order dated 08/30/09.
-An untimed restraint order dated 08/31/09.
-An untimed restraint order dated 09/01/09.
-An untimed restraint order dated 09/15/09.
-An untimed order to administer a medication to reduce gastric secretions, to discontinue intravenous fluids, to start an antibiotic medication around the percutaneous endoscopically placed gastrostomy site {PEG tube site, a feeding tube inserted through the stomach wall}, and to check ultrasound {test} of the gallbladder - regarding increased liver function tests.
-An untimed, undated restraint order authenticated by the physician on 09/17/09.
-An untimed restraint order dated 09/18/09.

During an interview on 01/06/10 at 1:11 p.m. the Director of Health Information Management (HIM), Staff M reviewed the patient's physician's orders and stated staff failed to date and/or time the orders as required by facility policy.

4. Record review of closed Patient #11's admission history and physical revealed staff admitted the patient on 10/26/09 with diagnoses including respiratory distress due to ARDS, asthma, high blood pressure and anemia.

Record review of the patient's physician's orders revealed the following:
-An untimed overprinted order set titled Ventilator Standing Orders dated 10/26/09.
-An untimed order to obtain culture of secretions dated 10/30/09.
-An untimed order for administration of an antibiotic via the feeding tube dated 11/21/09.
-An untimed order for nasal spray dated 11/05/09.
-An untimed order for Infectious Disease {physician} consultation dated 11/13/09.
-An untimed order for hematology laboratory testing in the morning and type and cross blood for transfusion if blood levels were below a specified level dated 11/18/09.
-An untimed order for pain medication dated 11/20/09.
-An untimed order for compassionate care dated 11/30/09.
-An untimed order to discontinue blood sugar and vital signs checks dated 12/01/09.
-An untimed order to consult a psychologist dated 12/03/09.
-An untimed order to end carbon dioxide monitoring dated 12/09/09.
-An untimed order to discontinue compassionate care, re-consult Infectious Disease {physician}, obtain blood testing, x-rays and re-start all medications dated 12/14/09.
-An untimed order to wean ventilator dated 12/18/09.

During an interview on 01/06/09 at 1:49 p.m. the Director of HIM, Staff M reviewed the patient's physician's orders and stated staff physicians failed to time orders as required.

5. Record review of closed Patient #12's admission history and physical revealed staff admitted the patient on 10/07/09 with diagnoses including blood infection, pneumonia, left foot infection, bilateral pleural effusions {fluid buildup around both lungs}, low blood sugar, septic shock, kidney failure, low blood potassium, lumbar back pain due to degenerative disc disease, atrial fibrillation {abnormal heart rhythm}, diabetes, high blood pressure and pressure ulcers.

Record review of the patient's physician's orders revealed the following:
-An untimed order for application of medication to pressure ulcers dated 10/14/09.
-An untimed order for dialysis dated 10/22/09.
-An undated, untimed order to {almost illegible} pull three liters over four hours.

During an interview on 01/06/10 at 1:50 p.m. the Director of HIM, Staff M reviewed the patient's physician's orders and stated the physicians failed to time and or date and time orders as required.

6. Record review of closed Patient #14's admission history and physical revealed staff admitted the patient on 10/06/09 with diagnoses including respiratory failure after tracheostomy tube placement, pneumonia, blood infections, traumatic brain injury after motor vehicle accident, seizure disorder, coronary artery disease, history of atrial fibrillation {abnormal heart rhythm}, high blood pressure, anemia, kidney failure and a requirement for hemodialysis, blood clotting problems and poor nutritional status.

Record review of the patient's physician's orders revealed an untimed restraint order dated 10/08/09.

During an interview on 01/06/10 at 2:00 p.m. the Director of HIM, Staff M reviewed the restraint order and stated staff failed to time and order as required.

Based on interview and record review facility staff failed to ensure all verbal orders were dated, timed and authenticated within forty eight hours in eight (Patient #16, #18, #3, #4, #5, #11, #13, #14 ) of twenty-three patient medical records reviewed for dated, timed and authenticated verbal orders. The facility census was 18 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records (provided during the survey) in part, directed physicians to provide the following:
-A complete, legible medical record for each patient.
-All orders must be dated, timed and signed by the ordering physician or allied health practitioner responsible for the patient's care.
-Verbal orders shall not be used routinely. All (other than Do Not Resuscitate) verbal or telephone orders will be authenticated within forty eight hours by the ordering physician or other licensed practitioner responsible for the patient's care.

Record review of the facility policy titled Orders: Verbal and Written orders, revised 11/09 directed, in part, the following:
-Written orders must be authenticated and dated by the person responsible for the order.
-Each drug order shall include time and date of order.
-In addition to the information required for a written order, verbal orders shall include date and time of entry.
-Verbal orders shall be subsequently authenticated (verified) and counter signed by the prescribing practitioner or other responsible practitioner within forty eight hours of receipt.

2. Record review of current Patient #16's admission history and physical revealed staff admitted the patient on 12/21/09 with diagnoses including respiratory failure, high blood levels of sodium, high blood pressure, and rapid heart rhythm, fluid accumulation in the lungs, schizophrenia, urinary tract infection, hernia repair, high blood cholesterol and urinary retention.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated, untimed verbal order to discontinue speech {therapy} dated 12/22/09.
-An unauthenticated verbal order to change treatments to three times a day dated 12/23/09 at 2:00 p.m.

3. Record review of current Patient #18's admission history and physical revealed staff admitted the patient on 12/16/09 with diagnoses including ankle osteomyelitis {infection in the bone}, diabetes, high blood pressure, history of atrial fibrillation, high blood cholesterol, osteoarthritis, gastroesophageal reflux disease {stomach acid back flows into the food pipe}, anemia, gout, low blood potassium and poor nutritional status.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated verbal order {written as a standing order} to provide an oral nutritional supplement and a bedtime snack dated 12/07/09 at 11:55 a.m.
-An unauthenticated verbal order {written as a standing order} to increase the caloric content of the patient's diet dated 12/22/09 at 12:40 p.m.

4. Record review of closed Patient #3's admission history and physical revealed staff admitted the patient on 08/20/09 for problems including respiratory failure after tracheostomy tube placement (a two to three inch metal or plastic tube placed in a surgically created opening in the windpipe to keep the airway open), history of aspiration pneumonia (pneumonia caused by oral or stomach contents into the lung), right sided MCA (a stroke cause by a problem involving the middle cerebral artery that supplies blood to a portion of the brain), diabetes treated with insulin and high blood pressure.

Record review of the patient's physician's orders revealed an undated, untimed verbal order form for ventilator adjustment and to draw a blood test the following morning.

During an interview on 01/06/10 at 1:11 p.m. the Director of Health Information Management (HIM), Staff M reviewed the patient's physicians orders and stated staff failed to date and time the verbal order as required by facility policy.

5. Record review of closed Patient #4's admission history and physical revealed staff admitted the patient on 11/20/09 with diagnoses including right knee infection after right total knee replacement and subsequent removal and arthrodesis {joint fusion to relieve pain}, multiple debridements {removal of dead flesh from a wound}with gastrocnemius muscle flap and delayed closure, wound vac {negative pressure device to form a vacuum seal on a wound}on the knee, right lower extremity osteomyelitis {infection in the bone}, diabetes, anemia and high blood pressure.

Record review of the patient's physician's orders revealed a telephone/verbal order dated 12/11/09 at 12:45 p.m., faxed from the physician on 12/29/09 with authentication but, without time and date of authentication.

During an interview on 01/06/10 at 1:05 p.m. the Director of HIM, Staff M reviewed the faxed physician's order and stated the physician failed to date and time the authentication as required.

6. Record review of closed Patient #5's admission history and physical revealed staff admitted the patient on 11/10/09 with diagnoses including respiratory failure after tracheostomy tube placement, a requirement for mechanical ventilator, infection in the blood, pneumonia, necrotic bowel and surgical resection {dead bowel tissue and surgical removal}, atrial fibrillation {abnormal heart beat}, blood coagulation problems, anemia, history of kidney problems, high blood pressure, history of stroke, pressure ulcers on the coccyx {final segment of the spinal column}and heels.

Record review of the patient's physician's orders revealed the following:
-A verbal order dated 11/11/09 at 12:00 for change in the wound care orders, faxed from the physician on 11/17/09 with authentication but, without time and date of authentication.
-A verbal order dated 11/20/09 at 10:30 a.m. for medication and obtain consent for debridement, faxed from the physician on 12/16/09 with authentication but, without time and date of authentication.
-An unauthenticated verbal order dated 11/28/09 at 10:30 p.m. for care of the peripherally inserted central catheter {PICC line for intravenous access}.
-An unauthenticated verbal order dated 12/12/09 at 6:00 p.m. for wound care.

7. Record review of closed Patient #11's admission history and physical revealed staff admitted the patient on 10/26/09 with diagnoses including respiratory distress due to ARDS {Acute Respiratory Distress Syndrome, a sudden failure of the respiratory system with fluid buildup in the air sacs of the lung and subsequent breathing difficulty and oxygen deprivation to vital organs}, asthma, high blood pressure and anemia.

Record review of the patient's physician's orders revealed the following:
-A verbal order dated 10/26/09 at 5:15 p.m. for substitution in tube feeding product with an authentication but without a date and time of authentication.
-An untimed verbal order dated 10/26/09 for pressure ulcer care.
-A verbal order dated 10/28/09 at 11:40 a.m. for chest x-ray with dated authentication but without time of authentication.
-A verbal order dated 10/28/09 at 4:37 p.m. for change in tube feeding rate with dated authentication but without time of authentication.
-An untimed verbal order dated 10/30/09 to discontinue ferrous sulfate.
-A verbal order dated 10/31/09 at 10:00 p.m. for insertion of a rectal tube due to liquid stools and decubitus wounds with authentication but without date and time of authentication.
-A verbal order directing tube feeding changes and obtain laboratory results dated 11/03/09 at 10:00 a.m. with authentication but without time and date of authentication.
-A verbal order dated 11/06/09 at 8:00 a.m. for dressing over a shoulder wound with authentication but without date and time of authentication.
-A verbal order dated 11/06/09 at 2:45 p.m. for dressing over a left ankle wound and for a dressing over left hip and sacral wounds with authentication but without date and time of authentication.
--A verbal order dated 11/11/09 at 9:00 p.m. to obtain blood cultures, urine cultures and sputum cultures, administer Tylenol via feeding tube and intravenous fluids with authentication but without date and time of authentication.
--A verbal order dated 12/06/09 at 5:35 p.m. for administration of antibiotic medication with authentication but without date and time of authentication.
--A verbal order dated 11/13/09 at 11:00 a.m. for care of the patient's pressure ulcers and consultation with a specialist with authentication but without date and time of authentication.
-An unauthenticated verbal order dated 11/20/09 at 9:30 a.m. for pain relieving spray at the bedside in preparation for {wound} debridement.
-A verbal order dated 12/03/09 at 1:05 p.m. for intravenous morphine with authentication but without date and time of authentication.
--A verbal order dated 12/07/09 at 12:10 p.m. for Speech Language Pathologist to assist in communication attempts with authentication but without date and time of authentication.
-An unauthenticated verbal order {recorded as a standing order} to change the rate of tube feeding dated 12/11/09 at 3:00 p.m.
-An unauthenticated verbal order for Tylenol per feeding tube dated 12/17/09 at 5:30 p.m.
-An unauthenticated verbal order for CT of the sinuses without contrast {dye} dated 12/21/09 at 10:30 a.m.
-An unauthenticated verbal order to resume tube feeding dated 12/21/09 at 3:58 p.m.
-An unauthenticated verbal order for blood coagulation studies in the morning and hold a medication dated 12/21/09 at 5:00 p.m.
-A verbal order dated 12/21/09 at 5:30 p.m. to hold all medications until after procedures with authentication but without date and time of authentication.
-An unauthenticated verbal order {recorded as a standing order} to change the rate of tube feeding dated 12/24/09 at 9:15 a.m.

During an interview on 01/06/09 at 1:49 p.m. the Director of HIM, Staff M reviewed the patient's verbal/telephone and verbal orders recorded as standing orders and stated staff physicians failed to date, time and/or authenticate the orders as required.

8. Record review of closed Patient #13's admission orders revealed staff admitted the patient on 11/30/09 with diagnoses including respiratory failure.

Record review of the patient's physician's orders revealed an unauthenticated telephone/verbal order dated 12/22/09 at 10:05 p.m. for a CT to rule out stroke.

During an interview on 01/06/10 at 1:52 p.m. the Director of HIM, Staff M reviewed the patient's verbal orders and stated the physician failed to authenticate the verbal order within forty eight hours as required.

9. Record review of closed Patient #14's admission history and physical revealed staff admitted the patient on 10/06/09 with diagnoses including respiratory failure after tracheostomy tube placement, pneumonia, blood infections, traumatic brain injury after motor vehicle accident, seizure disorder, coronary artery disease, history of atrial fibrillation {abnormal heart rhythm}, high blood pressure, anemia, kidney failure and a requirement for hemodialysis, blood clotting problems and poor nutritional status.

Record review of the patient's physician's orders revealed the following:
-A verbal order dated 10/15/09 at 3:56 p.m. to decrease the parenteral nutrition, restart the tube feeding and administer free water with authentication but without date and time of authentication.
-An unauthenticated verbal order dated 10/16/09 at 1:15 p.m. to decannulate the patient.
-An unauthenticated verbal order for blood cultures dated 10/29/09 at 7:30 a.m.
-An unauthenticated verbal order to change the hemodialysis treatments to no heparin protocol.
-An unauthenticated verbal order {written as a standing order} to run a potassium level from blood obtained this morning dated 10/26/09 at 7:30 a.m.
-A verbal order to use 2K+ bath for hemodialysis treatments dated 10/26/09 at 7:30 a.m. and authenticated via fax on 11/20/09.
-A verbal order dated 10/28/09 at 8:10 p.m. for Tylenol for fever, obtain a urinalysis and chest x-ray on the morning with illegible authentication and without date and time of authentication.
-An unauthenticated verbal order {written as a standing order} dated 10/29/09 at 10:45 a.m. for nursing to provide pureed snacks twice a day.
-A telephone/verbal order dated 10/30/09 at 4:17 a.m. to obtain blood testing for type and cross, consult Nephrology for transfusion orders with an illegible authentication and without a date and time of authentication.
-An unauthenticated verbal order {written as a standing order} dated 11/02/09 at 10:40 a.m. to change the tube feeding, continue the parenteral nutrition.
-A verbal order dated 11/04/09 at 6:15 a.m. to discontinue two medications with an authentication (on a fax dated 11/16/09) but without a date and time of authentication.
-A verbal order dated 11/16/09 at 10:05 a.m. to use heparin with the dialysis treatment with an authentication (on a fax dated 12/29/09) but without a date and time of authentication.

During an interview on 01/06/09 at 2:00 p.m. the Director of HIM, Staff M reviewed some of the patient's verbal orders and stated staff failed to consistently authenticate and date and time authentications as required.

Based on record review and interview facility staff failed to ensure a completed, authenticated history and physical was on the patient's medical record within twenty four hours of admission for seven (Patient #16, #17, #18, #19, #4, #11 and #22) of twenty-three patient medical records reviewed for completed, authenticated history and physicals within twenty four hours of admission. The facility census was 18 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records (provided during the survey) in part, directed physicians to provide the following:
-A complete, legible medical record for each patient.
-A complete admission history and physical examination recorded and placed in the medical records within twenty four hours of admission.

2. Record review of current Patient #16's admission history and physical revealed staff admitted the patient on 12/21/09 with diagnoses including respiratory failure, high blood levels of sodium, high blood pressure, and rapid heart rhythm, fluid accumulation in the lungs, schizophrenia, urinary tract infection, hernia repair, high blood cholesterol and urinary retention.

Record review of the patient's admission history and physical (reviewed on 01/06/10) revealed the physician failed to authenticate and complete the document.

3. Record review of current Patient #17's admission history and physical revealed staff admitted the patient on 12/30/09 with diagnoses including chronic obstructive pulmonary disease worsening and respiratory insufficiency, pneumonia, history of congestive heart failure, coronary artery disease, anemia, skin lesion and poor nutrition.

Record review of the patient's admission history and physical (reviewed on 01/06/10) revealed the physician failed to authenticate and complete the document.

4. Record review of current Patient #18's admission history and physical revealed staff admitted the patient on 12/16/09 with diagnoses including ankle osteomyelitis {infection in the bone}, diabetes, high blood pressure, history of atrial fibrillation, high blood cholesterol, osteoarthritis, gastroesophageal reflux disease {stomach acid back flows into the food pipe}, anemia, gout, low blood potassium and poor nutritional status.

Record review of the patient's admission history and physical (reviewed on 01/06/10) revealed the physician failed to authenticate and complete the document.

5. Record review of current Patient #19's admission history and physical revealed staff admitted the patient on 12/17/09 with diagnoses including lower extremity osteomyelitis {infection in the leg bone}, blood infection, chronic obstructive pulmonary disease {narrowing of airways in the lung with difficulty breathing}, morbid obesity, congestive heart failure, diabetes, history of cerebral palsy, anemia and poor nutrition status.

Record review of the patient's admission history and physical (reviewed on 01/06/10) revealed the physician failed to authenticate and complete the document.

6. Record review of closed Patient #4's admission history and physical revealed staff admitted the patient on 11/20/09 with diagnoses including right knee infection after right total knee replacement and subsequent removal and arthrodesis {joint fusion to relieve pain}, multiple debridements {removal of dead flesh from a wound}with gastrocnemius muscle flap and delayed closure, wound vac {negative pressure device to form a vacuum seal on a wound}on the knee, right lower extremity osteomyelitis {infection in the bone}, diabetes, anemia and high blood pressure.

Record review of the patient's discharge summary revealed the patient left the facility against medical advice on 12/14/09.

Record review of the patient's admission history and physical revealed the document was dictated on 11/20/09 and not authenticated until 12/29/09, after the patient had been discharged.

7. Record review of closed Patient #11's admission history and physical revealed staff admitted the patient on 10/26/09 with diagnoses including respiratory distress due to ARDS {Acute Respiratory Distress Syndrome, a sudden failure of the respiratory system with fluid buildup in the air sacs of the lung and subsequent breathing difficulty and oxygen deprivation to vital organs}, asthma, high blood pressure and anemia.

Further review of the patient's admission history and physical dated 10/26/09 revealed the physician failed to authenticate, date and time the authentication.

During an interview on 01/06/10 at 1:49 p.m. the Director of Health Information Management (HIM), Staff M reviewed the patient's admission history and physical and stated the physician failed to authenticate and complete the document within twenty four hours of the patient's admission.


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8. Record review of discharged Patient #22's admission history and physical revealed the patient entered the facility on 8/26/09 with diagnoses including a left hip ulcer with osteomyelitis (infection in the bone) and status-post surgical debridement (removal of dead flesh from a wound).

Record review of the patient's discharge summary revealed the physician discharged Patient #22 on 9/30/09.

Record review of the patient's admission history and physical revealed the physician dictated the document on 8/26/09 and did not authenticate the history and physical until 10/11/09, after the patient had been discharged.

Based on record review and interview facility staff failed to ensure each patient medical record was completed within thirty days of the patient discharge for three (Patient #5, #12, #14) of ten closed patient medical records reviewed for completion within thirty days of discharge. The facility census was 18 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records (provided during the survey) in part, directed physicians to provide the following:
-A complete, legible medical record for each patient.
-A discharge summary (clinical resume) shall be written or dictated on all medical records of patients hospitalized.
-The medical record will be deemed delinquent if not completed within thirty days of discharge.

2. Record review of closed Patient #5's admission history and physical revealed staff admitted the patient on 11/10/09 with diagnoses including respiratory failure after tracheostomy tube placement, a requirement for mechanical ventilator, infection in the blood, pneumonia, necrotic bowel and surgical resection {dead bowel tissue and surgical removal}, atrial fibrillation {abnormal heart beat}, blood coagulation problems, anemia, history of kidney problems, high blood pressure, history of stroke, pressure ulcers on the coccyx {final segment of the spinal column}and heels.

Record review of the patients consults revealed an unauthenticated consult for PEG tube placement {percutaneous endoscopically placed gastrostomy feeding tube or PEG tube is a feeding tube inserted through the stomach wall} dated 11/19/09.

Record review of the patient's physician's orders revealed the following:
-A verbal order dated 11/11/09 at 12:00 for change in the wound care orders, faxed from the physician on 11/17/09 with authentication but, without time and date of authentication.
-A verbal order dated 11/20/09 at 10:30 a.m. for medication and obtain consent for debridement, faxed from the physician on 12/16/09 with authentication but, without time and date of authentication.
-An unauthenticated verbal order dated 11/28/09 at 10:30 p.m. for care of the peripherally inserted central catheter {PICC line for intravenous access}.
-An unauthenticated verbal order dated 12/12/09 at 6:00 p.m. for wound care.

During an interview on 01/06/10 at 1:35 p.m. the Director of Health Information Management (HIM), Staff M:
-Reviewed the patient consultation and stated the physician failed to authenticate the consult within thirty days as required.
-Reviewed the patient's unauthenticated verbal orders and stated the verbal orders had not been authenticated with date and time of authentication; one verbal order had been faxed to the physician however the physician had not returned the order with dated, timed authentication and the one verbal order was not authenticated.

3. Record review of closed Patient #12's admission history and physical revealed staff admitted the patient on 10/07/09 with diagnoses including blood infection, pneumonia, left foot infection, bilateral pleural effusions {fluid buildup around both lungs}, low blood sugar, septic shock, kidney failure, low blood potassium, lumbar back pain due to degenerative disc disease, atrial fibrillation {abnormal heart rhythm}, diabetes, high blood pressure and pressure ulcers.

Record review of the patient's unauthenticated Expiration Summary revealed the patient expired on 11/01/09.

During an interview on 01/06/10 at 1:50 p.m. the Director of HIM, Staff M reviewed the patient's Expiration Summary and stated the physician failed to authenticate the document within thirty days of patient discharge as required.

4. Record review of closed Patient #14's admission history and physical revealed staff admitted the patient on 10/06/09 with diagnoses including respiratory failure after tracheostomy tube placement, pneumonia, blood infections, traumatic brain injury after motor vehicle accident, seizure disorder, coronary artery disease, history of atrial fibrillation {abnormal heart rhythm}, high blood pressure, anemia, kidney failure and a requirement for hemodialysis, blood clotting problems and poor nutritional status.

Record review of the patient's unauthenticated Expiration Summary revealed the patient expired on 11/16/09.

During an interview on 01/06/10 at 2:00 p.m. the Director of HIM, Staff M reviewed the patient's Expiration Summary and stated the physician failed to complete and authenticate the document within thirty days of the patient's discharge.

Based on policy review, review of facility investigation, interview and personnel file review the facility failed to identify and investigate possible diversion of a controlled substance in a timely fashion, allowing diversion to continue by one (Staff GG) of one staff member. The facility census was 18.
Findings included:
Review of facility policy MM 03.01.01 PCS 09-01 Controlled Drugs: Storage and Distribution and Accountability (General) showed, "The use of controlled drugs in the facility should be in accordance with all applicable laws and regulations. The Director of Pharmacy should ensure the use and accountability of controlled drugs within the facility is legal and accurate, and stored in a way to prevent diversion. Documentation should satisfy all relative statutes. The director will ensure that drugs treated as Controlled Substances by the State Board of Pharmacy in which the hospital is located are properly stored, dispensed and administered and that all records are properly documented and filed."
During an interview on 01/04/10 at 2:00 p.m. the Director of Pharmacy, Staff J said that the facility had an incident of diversion of Demerol in June and July 2009. Staff J said a Licensed Practical Nurse, Staff GG admitted to the diversion during an investigation.
Review of the facility investigation showed the facility hired LPN Staff GG on 05/13/09 as a staff nurse. The investigation showed a registered nurse approached the Director of Pharmacy, Staff J on 6/22/09 with concerns that the vials of Demerol 50 mg had been tampered with. The Director of Pharmacy determined the problem was probably a manufacturing defect. The Director of Pharmacy removed a box of 25 vials of Demerol from the medication room. The investigation showed no other investigation into possible diversion until staff again approached the Director of Pharmacy on 07/09/09. On 07/09/09 two boxes of 25 vials of Demerol had what appeared to be puncture holes in the protective caps. The boxes of Demerol were removed from the medication room by the Director of Pharmacy. The investigation showed the facility viewed a security camera video of the medication room. The video showed LPN Staff GG remove a box of Demerol from the medication dispensing machine. Staff GG shielded the camera from view and after a period of time returned the box of Demerol to the medication dispensing machine. The investigation showed administration interviewed Staff GG and he/she subsequently admitted to tampering with the Demerol vials. The facility terminated Staff GG, reported the tampering to the Bureau of Narcotics and Dangerous Drugs, the local police department and reported Staff GG to the State Board of Nursing.
During an interview with the Director of Pharmacy, Staff J on 01/04/10 at 1:55 p.m. Staff J said when staff approached him/her on 06/22/09 he/she looked at the vials of Demerol and concluded since all the vials looked the same it must have been a manufacturing defect. The director said he/she did not notify the manufacturer or investigate the issue any further. The director said on 06/22/09 he/she did not know of any nursing personnel who had any current or past actions against their license. The director said when staff approached him/her the second time, which was on 07/09/09 he/she contacted the manufacturer and concluded this was not a manufacturing defect. The director said the protective caps covering the Demerol vials looked like there were puncture holes through the caps. The director said facility administration conducted the investigation and concluded from watching the security video and interviewing Staff GG that he/she had diverted Demerol. The Director of Pharmacy said the facility informed him/her during the investigation that LPN Staff GG had a previous action against his/her nursing license for diversion of Demerol at another facility.
During an interview on 01/05/10 at 10:00 a.m. the Chief Nursing Officer/Chief Clinical Officer Staff K said the facility does not share personnel issues with the Director of Pharmacy. Staff K said the facility did not inform the Director of Pharmacy at the time of hire that LPN Staff GG had a previous action against his/her license for diversion of a narcotic.
Review of the personnel record for LPN Staff GG showed the facility hired Staff GG as a staff nurse and he/she began work on 05/13/08. A review of Staff GG's license showed at the time of hire Staff GG was working under a probationary license. The probationary period was 09/21/05 - 09/21/08. His/her license was on probation due to diversion of a controlled substance.
Review of the personnel record for the Director of Pharmacy, Staff J showed a hire date of 11/01/07 and Staff J became the Director of Pharmacy on 07/09/08.

Based on policy review, observation and interview the facility failed to ensure medications are kept in a locked, secured area to prevent access by unauthorized persons in the medication room. The facility has one medication room. The facility census was 18.

Findings included:

Review of facility policy MM 03.01.03, PCS 08-02 last reviewed 11/2006 showed, "The Director of Pharmacy should ensure the availability of a sufficient inventory of medical staff and hospital leadership approved emergency drugs in the pharmacy and patient care areas. Emergency drugs will be secured but readily available to the patient-care staff but not accessible to patients, visitors, and unauthorized personnel. They will be located in a locked room or secure area."

Observation of the medication room on 01/04/10 at 2:20 p.m. showed two trays with emergency drugs located on top of the medication refrigerator.

During an interview at 2:25 p.m. the Director of Pharmacy Staff J said these two trays are replacement trays for the emergency crash cart. The director said these trays are always located on top of the refrigerator and are not secured in a locked cabinet or drawer.

The two emergency trays contained medications too numerous to list.

Review of facility policy MM03.01.01, PCS 10-04 effective 1/09 showed, "The Director of Pharmacy or designee should conduct monthly inspections of all medication areas (e.g. nursing-care units and other areas where drugs are dispensed, administered, or stored ...) All medications, including OTC (over the counter) drugs, should be secured in an area that restricts pilferage."

Further observation of the medication room on 01/04/10 at 2:50 p.m. showed an unlocked refrigerator containing medications too numerous to list.

During an interview at 2:55 p.m. the Director of Pharmacy Staff J said the facility is attempting to secure a lock for the refrigerator in order to secure the medications. The director said when a key is obtained for an existing padlock, the refrigerator will be locked. The director said the facility has been trying to obtain a key since the facility had a Joint Commission survey in November 2009.

The director said housekeeping staff have access to the medication room at any time in order to clean the room.

Based on policy review, observation and interviews, the facility failed to properly label multi-use medication bottles and failed to ensure expired medications were not available for patient use. The facility census was 18.

Findings included:

Review of facility policy MM 05.01.09; NPSG 01.01.01 Drug Preparation/Dispensing Labels (Pharmacy) showed, "All drugs used in the facility should be neatly, accurately, and appropriately labeled according to applicable law and regulation." Section three (3) documents: All labels should include at least:
a. Patient name and location
b. The proprietary and/or nonproprietary name of the drug
c. Drug strength
d. Dosage form
e. Expiration time when expiration occurs in less than 24 hours
f. Expiration date, when hot used within 24 hours
g. Quantity of drug (if not apparent on container)
h. Appropriate accessory and cautionary statements or supplemental labels as appropriate
i. Compounded I.V. (in the vein) admixtures require date prepared and diluents used
j. Individualized medications will contain directions for use on the label

Observation of the medication room on 01/04/10 at 1:45 p.m. showed an open bottle of Pink Bismuth (an anti-diarrhea medication and antacid). The only documentation on the label is an opened date of 12/29/09. The medication bottle did not contain a patient label.

During interview on 01/04/10 at 1:50 p.m. the Director of Pharmacy Staff J said that the medication should be discarded and not used.

Observation in the medication room on 01/05/10 at 9:20 a.m. showed a 30 cc bottle of MD-Gastroview (a contrast agent for radiographic examination of segments of the gastrointestinal tract) sitting on a cart. The only documentation on the label is an opened date of 12/09/09 on the container. The medication bottle did not contain a patient label.

During an interview on 01/05/10 at 9:30 a.m. Licensed Practical Nurse (LPN) Staff I said he/she did not know why the medication is sitting on the cart or what patient it was used for. Staff I said that the medication should be discarded.


Review of facility policy MM 03.01.01, PCS 10-04 effective 01/09 showed, "The Director of Pharmacy or designee should conduct monthly inspections of all medication areas (e.g. nursing-care units and other areas where drugs are dispensed, administered, or stored." Further review showed, "Outdated or otherwise unusable drugs are identified, removed from stock, and stored to prevent their distribution and administration."

Observation of the medication room on 01/04/10 at 2:20 p.m. showed two trays with emergency drugs located on top of the medication refrigerator. One tray is marked with an expiration date of 12/31/09.

During an interview at 2:25 p.m. the Director of Pharmacy Staff J said these two trays are replacement trays for the emergency crash cart. The director said the tray with an expiration date of 12/31/09 should have been replaced by pharmacy.

The expired emergency tray contained medications too numerous to list.

Based on interview and record review facility staff failed to develop and implement a system to ensure patient's diet orders were prescribed with the practitioners knowledge and consistently authenticated by the practitioner responsible for the patient's care in three (Patient #18, #3, #14) of twenty-three patient medical records reviewed for diet orders. The facility census was 18 patients.

Findings included:

1. Record review of an undated copy of the facility Medical Staff Rules and Regulations, Section B. Medical Records (provided during the survey) in part, directed physicians to provide the following:
-All orders for treatment shall be in writing. Registered Dietitian may receive and transcribe verbal orders from attending physicians for nutritional support.
-Standing orders and/or instruction sheets shall be instituted only after approval of the Medical Executive Committee. Such standing orders and/or instruction sheets shall be reviewed annually and revised as necessary. All standing orders and/or instruction sheets must be signed and dated by the responsible physician.

Record review of the facility policy titled Nutrition: Therapeutic Diets, #PC.15.9, revised 10/08 directed, in part, the following:
-The Registered Dietitian plans therapeutic diets.
-The Clinical Dietitian makes pertinent notes in the medical record regarding patient acceptance of diet, nutritional adequacy of diet and patient progress.
-The Speech Therapist may write orders for adjustment of diet consistency based on clinical expertise

Record review of the facility policy titled Nutrition: Medical Nutrition Therapy Order Writing by Registered Dietitians, #PC.15.10, and reviewed 02/09 directed, in part, the following:
-The physician has direct control of the patient care in all cases and at all times.
-The Registered Dietitian will be able to write medical nutrition therapy orders including enteral and/or parenteral nutrition and water flushes.
-Advance or down grade diets as appropriate.
-Order supplements and snacks.
-Order laboratory tests pertinent to nutrition monitoring.
-Order feeding assistance for patients.
-Vitamin, mineral supplements, pro-biotics may be ordered as a verbal order.

2. Record review of current Patient #18's admission history and physical revealed staff admitted the patient on 12/16/09 with diagnoses including ankle osteomyelitis {infection in the bone}, diabetes, high blood pressure, history of atrial fibrillation, high blood cholesterol, osteoarthritis, gastroesophageal reflux disease {stomach acid back flows into the food pipe}, anemia, gout, low blood potassium and poor nutritional status.

Record review of the patient's physician's orders revealed the following:
-An unauthenticated verbal order {written as a standing order by the dietitian} to provide an oral nutritional supplement and a bedtime snack dated 12/07/09 at 11:55 a.m.
-An unauthenticated verbal order {written as a standing order by the dietitian} to increase the caloric content of the patient's diet dated 12/22/09 at 12:40 p.m.

3. Record review of closed Patient #3's admission history and physical revealed staff admitted the patient on 08/20/09 for problems including respiratory failure after tracheostomy tube placement (a two to three inch metal or plastic tube placed in a surgically created opening in the windpipe to keep the airway open), history of aspiration pneumonia (pneumonia caused by oral or stomach contents into the lung), right sided MCA (a stroke cause by a problem involving the middle cerebral artery that supplies blood to a portion of the brain), diabetes treated with insulin and high blood pressure.

Record review of the patient's physician orders revealed a physician authenticated standing order written by the dietitian dated 08/24/09 at 3:00 p.m. to increase in tube feeding rate.

4. Record review of closed Patient #14's admission history and physical revealed staff admitted the patient on 10/06/09 with diagnoses including respiratory failure after tracheostomy tube placement, pneumonia, blood infections, traumatic brain injury after motor vehicle accident, seizure disorder, coronary artery disease, history of atrial fibrillation {abnormal heart rhythm}, high blood pressure, anemia, kidney failure and a requirement for hemodialysis, blood clotting problems and poor nutritional status.

Record review of the patient's physician's orders revealed the following:
-A physician authenticated verbal order dated 10/15/09 at 3:56 p.m. to decrease the parenteral nutrition rate of infusion, restart the tube feeding and administer free water written by a contract dietitian.
-An unauthenticated verbal order {written as a standing order by a Speech Therapist} dated 10/29/09 at 10:45 a.m. for nursing to provide pureed snacks twice a day.
-An unauthenticated verbal order {written as a standing order by the facility dietitian} dated 11/02/09 at 10:40 a.m. to increase the tube feeding, continue with the current parenteral nutrition, specific amino acid, dextrose and lipid infusions, if the patient tolerated the increase in tube feeding rate to a calculated goal rate every twelve hours then, decrease the parenteral nutrition infusion with each increase in tube feeding.

5. During an interview on 01/06/10 at approximately 9:30 a.m. the Registered Dietitian stated the following:
-She routinely wrote patient orders for tube feedings, water flushes and parenteral (infusion through the veins) nutrition without further physician authentication (indicating physician's knowledge and consent).
-The facility patient admission order set had an option for the physician to choose in conjunction with the initial diet order, "Dietitian to manage nutritional therapy".
-With the selection of the option to allow the dietitian to manage nutritional therapy the Dietitian felt she could order feeding modalities (enteral and intravenous) as implied by the facility policy titled Nutrition: Medical Nutrition Therapy Order Writing by Registered Dietitians, #PC.15.10, and reviewed 02/09.
-The facility admission order set also routinely included overprinted order sheets for Ventilator Standing Orders (standing orders are a pre-approved set of possible therapeutic interventions from which the practitioner can select for use with their patient), Sliding Scale Insulin Orders, Pain Management Standing Orders and Oxygen Standing Orders each with set parameters for the practitioner to select and restricting the actions each professional could perform.
-The Dietitian stated the facility did not have an overprinted form for Medical Nutrition Standing Orders with specifically outlined parameters she could choose to perform for any patient.
-The Dietitian used the term "standing orders" but was really writing verbal orders (verbal orders required a physician authentication indicating knowledge and consent).
-She felt by writing the nutrition orders as standing orders, she did not need physician authentication for medical nutrition modality she ordered.
-Sometimes the physicians authenticated her standing orders and sometimes they did not.

Based on observation and interview the facility failed to insure that a soiled utility room with a clinical sink or equivalent flushing rim fixture or work counter with a sink suitable for hand-washing was provided for the nursing units. This affects all patients in a census of 18.
Findings included:
Observation during all days of the survey revealed that there is one room labeled as a soiled utility room across from the respiratory office. In this room was one red tub for bio-hazardous materials, four trash cans and one dirty linen cart. There was no sink observed in this room. There was one room next to this and labeled as clean storage. There were two rooms by each of the two nurses stations labeled clean storage. The only room indicated as a soiled utility room did not have any sink in that area.
During interview on 01/04/10 at 2:00 p.m., Staff Z said that all trash and soiled linen go directly to the dedicated room across from the respiratory services office and that there are no soiled linen/trash rooms on the floor.
Section 19 CSR 30-20.030 section (5) (E) states a soiled workroom or soiled holding room shall contain a clinical sink or equivalent flushing rim fixture, work counter with a sink suitable for hand-washing, waste receptacle and linen receptacle.

Based on observation, facility policy review and interviews, the facility failed to ensure that supplies and medications are stored to ensure they are protected against contamination in the room dedicated as the outpatient dialysis supply room, and failed to ensure that a portable C-arm (radiology equipment) was inspected periodically. The census at the time of the survey was eighteen (18) patients.

Findings included:

The facility policy titled, Drug Storage, General, policy number: MM.44.1, PCS 04-01, review date of 01/09 states, "Keep storage areas clean, uncluttered and free from trash, insects, rodents, and vermin. If lower shelves are not sealed to the floor, allow sufficient space underneath to permit access for cleaning.
Do not store drugs and supplies on the floor".

2. Observation of the dialysis storage room on 01/05/10 at 4:00 p.m. and on 01/06/10 at 9:30 a.m. showed the following:

- Three jugs of vinegar, two bottles of bleach, three jugs labeled Citrasate, and a container labeled acetic acid 5% located on the floor, under the sink.

- A box of Citrasate, containing four (4) one gallon jugs on the floor. (Citrate solution is an anticoagulant used during dialysis if patients are allergic to heparin). (Dialysis is the removal of toxic substances in the blood as a result of inadequate kidney function).

- A box of Bicarbonate containing three (3) 6.4 liter jugs (a salt of carbonic acid in which one of the hydrogen atoms is replaced by a metal: sodium bicarbonate), used during dialysis.

3. On 01/05/10 at 4:10 p.m. Staff P, Infection Control Practitioner, observed the above and said that these items are usually stored on a table and should not be on the floor.

4. On 01/06/10 at 9:30 a.m. Staff AA, Clinical Manager of Fresenius Medical Care, and responsible for oversight of outpatient dialysis in the facility said the following:
- Nothing should be stored on the floor.
- Bleach, vinegar, and acetic acid are used to disinfect the dialysis machines.
- The patient room they are using for storage is not large enough for their equipment and supplies.
- He/she had discussed with the facility.



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4. Review of the documents titled asset detail report and contract service report done on 09/01/09 and reviewed on 01/04/10 indicated an annual preventative maintenance inspection had been done on the portable C-arm. The signature of the person doing the testing was not that of a physicist.
During an interview on 01/05/10 at 3:40 p.m. Staff Z stated that the inspection had been done in conjunction with the host hospital and their radiology department. During several phone calls with the host hospital it was determined that the person doing this inspection was not a physicist and that there was a possibility that a physicist had done a separate inspection but this report was not available.
Section 19 CSR 30-20.102 of Missouri state licensure for hospitals states under paragraph (9) that there shall be periodic inspection of equipment by a medical physicist qualified to furnish complete evaluation. Documentation shall be maintained and available for two years.

Based on observation, facility policy review, and interview, facility staff failed to follow professional standards of care and facility policy for two out of five patients observed receiving care (Patient #6, Patient #8). The census at the time of the survey was eighteen (18) patients.

Findings included:

1. Facility policy titled Standard Precautions, policy number: IC.18, date of revision: 10/08 states under "Basic rules of Standard/Universal Precautions: 1. (a) Wear gloves when touching blood, body fluids, secretions, excretions and contaminated items. (f) Remove gloves immediately after use, dispose of in an appropriate container and wash hands. (i) Gloves are an adjunct, not a substitute for hand washing.
g. Patient care equipment - dispose of single use items appropriately after use. Reusable items are to be appropriately cleaned and reprocessed before being used again".

Facility policy titled Cleaning, Disinfection & Sterilization of Patient Care Items, policy number: IC.27, date of revision 01/09 states, "Non critical items - are those that either do not ordinarily touch the patient or touch only intact skin. Examples: crutches, backboards, blood pressure cuffs, and a variety of other medical accessories. Depending on the particular piece of equipment or item, washing with a detergent may be sufficient".

2. Observation on 01/05/10 at 9:15 a.m. of indwelling foley catheter care (rubber tubing introduced into the bladder to provide for a continuous flow of urine from the bladder) to Patient #6 by Staff G, Unit Technician showed signage on the patient's door which stated, "Contact Precautions (In addition to Standard Precautions) 1. Private Room - when a private room is not available, cohort with patient(s) who have active infection with the same microorganism but with no other infection. 2. Gloves - wear gloves when entering room. Change gloves after contact with infective material. Remove gloves before leaving patient's room. 3. Wash hands - with antimicrobial agent immediately after glove removal and before leaving the patient's room. 4. Gown - wear if you anticipate that your clothes will have contact with the patient, environmental surfaces, or items in the patient's room or if the patient has any of the following: Incontinent, diarrhea, colostomy, ileostomy, wound drainage not contained by a dressing. Remove gown before leaving the patient's environment. 5. Transport - Limit the movement/transport of patients from room to essential purposes only. During transport, ensure that all precautions are maintained at all times. 6. When possible, dedicate the use of noncritical patient-care equipment to a single patient. If common equipment is used, clean and disinfect between patients."

Staff G, gowned, gloved, entered the room, performed foley catheter care, and repositioned the patient in bed. The walkie-talkie (mobile communication device) located in Staff G's pocket rang. Staff G reached under the isolation gown with contaminated gloves and retrieved/answered the device, then placed the device on the patient's bed. Staff G removed gown, gloves, performed hand hygiene and placed the device in his/her pocket and left the patient's room without cleaning the device.

3. Observation on 01/05/10 at 10:50 a.m. of wound care to Patient #8 showed Staff U remove soiled dressings from wounds on the right and left lower buttocks and coccyx areas. Staff U removed gloves and donned clean gloves prior to applying clean dressings, but failed to perform hand hygiene prior to donning clean gloves.

4. During an interview on 01/05/10 at 3:30 p.m., Staff P, Infection Control Practitioner (ICP) said that staff should always wipe down any items used in patient rooms which come in contact with patients or environmental surfaces prior to leaving the room, especially when patients are on contact isolation precautions.

During this interview, Staff P said that he/she would expect staff to change and perform hand hygiene after removing a dirty dressing and applying a clean dressing.

Based on observation, and facility policy review, facility staff failed to follow the facility's internal policy for one of two patients observed receiving medication through a gastrostomy tube (Patient #7). The census at the time of the survey was eighteen (18) patients.

Findings included:

1. Facility policy titled Gastric Tubes: Medication Administration, policy number: PC.13.3 with date of revision on 01/09 states, "Purpose, to describe procedures for medication administration via gastric tube. Procedure, 2. Check placement of tube: b. Obtain gastric content by aspirating with 60 ml. [milliliters}syringe. c. Auscultate with stethoscope over gastric area while 60 ml. of air is inserted into tube and a rush of air is heard".

2. . Observation on 01/05/10 at 9:30 a.m. of medication administration to Patient #7 via gastrostomy tube (tube placed in stomach to administer fluids, medication and nutrition to patients unable to swallow) showed Staff D administer Plavix (cardiovascular medication) 75 mg. {milligrams}, Lovenox (anti-coagulant) 2.5 mg., Guafenesin (expectorant) 200 mg., Glycopyrrolate (anticholinergic) 1 mg., Zyprexa (anxiolytics) 2.5 mg., and a Multivitamin into the patient's gastrostomy tube. Staff D did not aspirate for gastric contents or auscultate with a stethoscope over gastric area prior to administering the medications.