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Based on observations, staff interviews, and medical record review the facility failed to ensure patient's rights to receive care in a safe environment as evidenced by:

Failure to ensure the safety of one pediatric patient who did not have a patient identifier on (Patient #8).

Failure to investigate and ensure the safety of the pediatric population relating to the detachment of pilot balloons from tracheostomy tubes resulting in the tubes being replaced (Patient #1, #4, #5 and #6).

Failure to investigate and ensure the safety of the pediatric population relating to the frequent documented "severing" of G-J tubes (gastrojejunostomy tube) at the y port resulting in the replacement of the tubes (Patient #1, #11, and #13).

Failure to ensure the pediatric population does not have suction catheters attached to them while the suction is on (Patient #20 and Patient #21).

Failure to prevent ten unplanned tracheostomy decannulations in a five month period resulting in the reinsertion of the tracheostomy tube.

Failure to ensure the hospital staff follows hand hygiene prior to providing care to the pediatric population (Staff #2, #7, #21, and #33).

The findings include:

Patient #8 observed with no identifier on the date of 02/05/2014 at 10:30 am on the Pediatric Unit.

Patient #1, #4, #5, and #6 all had incidents of detached pilot balloons. Some were documented as "severed" at the base of trach (tracheostomy) site. Cross reference Tag 0144.

Patient #20 and Patient #21 had documented incidents of having "suction catheter attached while the suction on. Neither patient was able to remove the suction. Cross reference Tag 0144.

Documentation on adverse event forms of ten unplanned decannulations (removal of tracheostomy tube) over a 5 month period.

Four of four nursing (Staff #2, #7, #21, and #33) staff observed not using hand hygiene prior to touching the patient. .







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Based on document reviews, staff interviews, and observations the facility's nursing staff failed to furnish care and service to ensure patient safety as evidenced by:

Failure to ensure adequate staffing to provide patient care.

Failure to ensure the supervision and evaluation of the nursing care for each patient. (Eight documented night shifts without a registered nurse on the unit).

Failure to use verbal orders infrequently and to follow hospital policy related to authorized personnel receiving verbal orders (seven of twenty medical records and Staff #6).

Failure to ensure pediatric patient (Patient #8) had a patient identifier on.

Failure to reassess (four hours from last documented assessment) a pediatric patient (Patient #9) after documenting a change in the patient's condition.

Failure to notify the medical doctor of a change in the patient's (Patient #9) condition.

Failure to notify the medical doctor of adverse events (multiple incidents of detached and missing pilot balloons from tracheostomy tubes) involving pediatric patients (Patient #1, #4, #5, and #6).

Failure to ensure suction catheters are not attached to pediatric patients (Patient #20 and #21) with the suction on.

Failure to monitor the pediatric patient population to prevent 10 unplanned decannulations.

Failure to use verbal orders infrequently and to follow hospital policy relating to verbal orders (seven of twenty medical records and Staff #6).

The findings included:

The Pediatric Unit had five documented incidents of pilot balloon detachments with the balloons missing between 11/26/2013 and 12/28/2013. Some of the adverse event forms and the nurses notes documented the "balloons were severed." The Pediatric Unit had approximately 7 incidents involving gastrojejunostomy tubes (feeding tube) between 07/29/2013 and 12/24/2013. Some of the incidents were documented in the nurses notes and on the adverse event form as "G-J tube severed at the y port." The Pediatric Unit had ten unplanned decannulations between 6/10/2013 and 11/26/2013.

Based on observations and interviews the hospital failed to maintain an environment to ensure the safety of patients as evidenced by:

Failed to ensure an acceptable level of safety and quality by not performing routine preventative maintenance on nine of thirteen ventilators on the pediatric unit.

Failed to have a policy on preventative maintenance of equipment.

Failed to provide a secure Pediatric Unit.

The findings included:

Two Medical Facilities Inspectors were able to gain access to the hospital on February 10, 2014 at approximately 7:00 pm through an unsecured and unmonitored front entrance (not the main entrance). The two Medical Facilities Inspectors were able to access the Pediatric Unit.
An interview was conducted with Staff #27 on the afternoon of February 6, 2014 by two Medical Facilities Inspectors in the first floor conference room. Staff #27 confirmed the hospital has security cameras. Staff #27 confirmed the security cameras are not always being observed by security. Staff #27 reported the security checks can take up to an hour and after the operator leaves at 12:00 am no hospital staff would be watching the hospital security cameras during the routine security checks. Staff #27 verified the pediatric unit has a camera at the entrance of the unit. Staff #27 verified if on routine checks no one would be watching the camera. Staff #27 confirmed the pediatric unit could be accessed unnoticed.
Staff #18 was interviewed on 02/05/2014 by two Medical Facilities Inspectors at approximately 3:15 pm in the first floor conference room. Staff #18 reported other night staff from other areas in the hospital come for coffee on the Pediatric Unit. Staff #18 confirmed POD 1 is the area in the Pediatric Unit where most of the detached and missing pilot balloons adverse events have occurred. Staff #18 confirmed POD 1 (area where multiple pediatric patients are in beds) is closest to the entrance to the Pediatric Unit. Staff #18 confirmed there could be a time when all staff were busy caring for patients in another POD and someone could enter the unit unnoticed.

Based on document reviews and interviews the facility failed to assure the facility has trained staff to appraise an emergency situation.

The findings included:

Staff #36 was interviewed on 02/07/2014 at approximately 12:35 pm. Staff #36 verified the hospital has a Code Policy (cardiac arrest). Staff #36 verified the hospital has no drugs on the code cart. Staff #36 verified the hospital has no AED (automated external defibrillator) or defibrillator (device used to deliver a brief electric shock to the heart) in the hospital. Staff #36 reported the staff had no "formal inservice on codes." Staff #36 reported staff have Basic Life Support. Personnel files reviewed on 02/11/2014 verified this information. Staff #36 verified staff are to call a code when pulseless. Staff #36 verified the Code Policy includes calling the operator during the day to initiate a response to a code. Staff #36 verified the number to call at night for a Code is 333. Staff #36 confirmed no operator is in the hospital at night. Six of ten hospital staff interviewed did not know the number to call a Code. The results of the interviews are as follows:
1) Staff #18 interviewed by two Medical Facilities Inspectors on 02/05/2014 at 3:15 pm stated "don't remember how to call a code. I never have had to call one."
2) Staff #26 was interviewed on 02/06/2014 at approximately 4:45 pm by two Medical Facilities Inspectors in the first floor conference room. Staff #26 was unable to remember the number to call a code. Staff #26 did look at his/ her name badge to obtain the number 333 to call a code.
3) Staff #16 was interviewed by phone on 02/05/2014 at approximately 1:15 pm by two Medical Facilities Inspectors. Staff #16 reported "not sure of the number."
4) Staff #19 was interviewed by phone by two Medical Facilities Inspectors in the first floor conference room at 02/07/2014 at approximately 9:30 am. Staff #19 reported he/she thought the number "use to be 456 but think 111."
5) Staff #21 was interviewed on 02/06/2014 by one Medical Facilities Inspector at approximately 9:30 am. Staff #21 stated "forgot the number."
6) Staff #25 was interviewed on 02/06/2014 by phone at approximately 4:00 pm by two Medical Facilities Inspectors in the first floor conference room. Staff #25 when asked how to call a code stated "never had to do it. Don't remember."

Staff #36 was informed of the findings on February 7, 2014 at approximately 12:35 pm. Staff #36 reported staff could look at "name badge for the code number."

A phone interview was conducted with Staff #16 on 02/05/2014 at approximately 1:15 pm by two Medical Facilities Inspectors. Staff #16 confirmed the Pediatric Unit often does not have a registered nurse physically present on the unit. Staff #16 reported he/she "gets the charge nurse from 2 east or the nursing supervisor." Staff #16 was interviewed a second time on 02/11/2014 at approximately 2:00 pm in the conference room by two Medical Facilities Inspectors. Staff #16 confirmed he/she was caring for Patient #9 on 12/09/2014. Patient #9 had a diagnosis of mental retardation, seizures, tracheostomy, gastrostomy, and a history of deep vein thrombosis. Patient #9 had a do not resuscitate order. Staff #16 verified the staffing on 12/09/2014 included two licensed practical nurses and two certified nursing assistants. Staff #16 reported there was no registered nurse physically present on the unit the night of 12/09/2013. Staff #16 was provided Patient #9's medical record. Staff #16 verified the nursing note written on 12/09/2013 reported Patient #9's heart rate of 148 upon initial assessment documented by Staff #16 at 7:20 pm. Staff #16 reported "148 was not a normal heartrate" for Patient #9. Staff #16 confirmed the nursing note reported Patient #9 had a "slightly distended abdomen and no residuals." Staff #16 reported he/she thought Patient 9's elevated heartrate was due to pain although Patient #9 had been medicated for pain approximately two hours prior to the initial assessment.
Staff #16 verified at 11:15 pm he/she was called to Patient #9's bedside by a respiratory therapist and two certified nursing assistants. Staff #16 verified the documentation in the clinical record reported Patient #9 was SOB (short of breath) and using accessory muscles. Staff #16 verified he/she had been told Patient #9 had bitten lip. Staff #16 stated "we thought the patient had a seizure." The facility policy #8.21 Seizure Document was received on 02/06/2014 at 3:10 pm. Under section three the policy states "notify MD (medical doctor) of change in patient condition." Staff #16 verified the medical doctor was not notified at 11:15 pm. Staff #16 verified documentation in Patient #9's medical record stated "abdomen extremely distended. Patient had bowel movement. Residual 700 cc of light brown colored liquid. Bowel sounds unable to hear." Documentation in Patient #9's clinical record indicates the nursing supervisor was at Patient #9's bedside at 11:30 pm. Staff #16 reported the staff repositioned Patient #9.
Staff #16 confirmed the medical doctor was not called to notify of the change in Patient #9. Staff #16 verified documentation in Patient #9's medical record reports a change in breathing noted by Staff #16 at 1:15 am. Staff #16 stated he/she "could not remember whether he/she went for the registered nurse on 2 east or sent the other licensed practical nurse." Documentation on the nursing note dated 12/10/13 indicates the registered nurse arrived at Patient #9's bedside at 1:25 am. Nursing documentation for the same time indicates Patient #9 had no heartrate and pupils were fixed and dilated. Patient #9 was pronounced dead at 1:30 am. The first call to the medical doctor regarding Patient #9 was placed at 1:35 am. Staff #16 confirmed the medical doctor was never called about the change in Patient #9's condition. Staff #16 verified it is not unusual to not have a registered nurse physically on the Pediatric Unit at night.

Documentation in Patient #11's medical record and on the adverse event form dated 12/24/2013 at 9:09 pm states "G-J tube with extensions severed at the y port." Patient #11's medical record and adverse event form were reviewed on February 5, 2014 and February 6, 2014. Documentation in the medical record dated 12/24/2013 reports the G-J tube was "patent" at 7:20 pm. Documentation in the nursing note dated 12/24/2013 at 9:09 pm states "G-J tube with extensions severed at the y port." Documentation by Staff #16 reports the charge nurse on another floor and the nursing supervisor were notified at 9:09 pm on 12/24/2013. Staff #16 notified the medical doctor at 9:20 pm on 12/24/2013. Patient #11 was unable to receive hydration, nutrition, or medications due to the G-J tube being "severed" at the y port.
On 12/25/2013 at 6:30 am Staff #16 was called to the Patient 11's bedside "as patient not ventilating." Documentation on the adverse event report dated 12/25/2013 reports Patient #11 was being manually (by ambu bag) ventilated with 100 percent oxygen. Documentation on the adverse event report dated 12/25/2013 states "patient had not received medications via G-J tube since 8:00 pm the night of the 24th." The adverse event report documentation dated 12/25/2013 reports the G-J tube "torn and taped and non-functional for several days." Staff #16 notified medical doctor and Patient #11 was transported to the local pediatric referral center. Staff #16 verified no registered nurse was scheduled to work on the Pediatric Unit the night of 12/24/2013.
Two Medical Facilities Inspectors interviewed Staff #16 by phone on 02/05/2014 at 1:10 pm. Staff #16 verified the findings in Patient #11's medical record. Staff #16 reported being told in the past by Staff #18 to "try harder to get the G-J tubes unclogged." Staff #16 reported Staff #18 has "pulled and milked G-J tubes" in an attempt to get the tube unclogged.
Staffing schedules were reviewed on 02/15/2014 at 1:30 pm. Two licensed practical nurses were scheduled to work the night shift of 12/24/2013.

This Standard is not met as evidenced by:
Based on observations, document reviews, and interviews the facility failed to provide care in a safe setting for:

1) One (Patient #8) of twenty patients (#1- #20) observed did not have a patient identifier.

2) Three patients (Patient #1, #11, and #13) of twenty patients (Patients #1-#20) had a total of eight (8) incidents of gastrojejunostomy tubes (feeding tube placed for long term use) found "severed at the y-port or broken at the port."

3) Two (Patient #20 and Patient #21) of twenty patients (Patients #1-#20) had documentation of an adverse event where a "suction catheter attached to the patient with the suction on."

4) Four (Patients #1, #4, #5, and #6) of twenty patients (Patients #1-#20) had five documented incidents of pilot balloon detachment with the balloons missing.

5) Four of four nursing staff (Staff #2, #7, #21, and #33) observed while on the Pediatric Unit did not follow hospital policy regarding hand washing.

6) Ten unplanned tracheostomy decannualtions occurred between 6/10/2013 and 11/26/2013 on the Pediatric Unit.

The findings included:

1) Patient #8 was observed in his/her crib on 02/05/2014 at approximately 10:30 am. Patient #8 did not have a patient identifier on. Staff #31 was present at the time of the finding.

2) Documentation in the patient's record and on the adverse event form reported Patient #1 was found on 07/29/2013 with the "G-J tube severed at the junction." The patient record and the adverse event form was reviewed on February 5, 2014 and February 6, 2014. The gastrojejunostomy tube (G-J tube) was found by Staff #19 at 6:15 am. Patient #1 was sent to the local pediatric referral hospital for G-J tube replacement. A phone interview was conducted by two Medical Facilities Inspectors with Staff #19 on 02/06/2014 at 11:15 am. Staff #19 confirmed he/she had been moved off the Pediatric Unit due to the problem with G-J tubes. Staff #19 stated "would never do anything to hurt the children." Staff #19 verified "2 or 3 times" he/she had found the G-J tubes "breaking at the port." Staff #19 reported he/she thought the tubes were "defective." An interview was conducted with Staff #26 by two Medical Facilities Inspectors in the first floor conference room on 02/06/2014 at approximately 4:30 pm. Staff #26 reported the facility had reached out to the local pediatric referral center regarding the number of adverse events with the G-J tubes. Staff #26 reported the facility had begun using extension tubing with the G-J tubes.

Documentation in the patient's record and on the adverse event form reported Patient #1 was found on 08/23/2013 with the "G-J tube severed at the y port." The patient record and adverse event form was reviewed on February 5, 2014 and February 6, 2014. The G-J tube was found at 9:00 pm by Staff #19. Patient #1 was sent to the local pediatric referral hospital for G-J tube replacement.

Documentation in the patient's record and on the adverse event form reported Patient #1 was found on 08/24/2013 with the "G-J tube severed at the junction." The patient record and the adverse event form were reviewed on February 5, 2014 and February 6, 2014. The G-J tube was found at 10:50 pm by Staff #16. Patient #1 was sent to the local pediatric referral center for gastrostomy tube placement.

Documentation in the patient's record and on the adverse event form reported Patient #11's G-J tube was found "clogged at 7:00 pm" on 09/10/2013. Patient #11's medical record and adverse event form were reviewed on February 5, 2014 and February 6, 2014. Documentation on 09/10/2013 by Staff #26 indicates an order was obtained to give medications and tube feedings via the Gastrostomy part of the tube. Documentation on the adverse event report dated 09/28/2013 indicates on 09/10/2013 Patient #11 was suppose to be sent for a G-J tube replacement secondary to "clogging and aneurysms along the tubing." The port was found to be flushing after hours of being administered Zenpep (pancreatic enzyme) and Sodium Bicarbonate (a white crystalline powder used as a electrolyte and systemic alkalizer). Use of the tube was resumed until the "J port tubing burst" on 09/28/2013. Patient #11 was sent to the local pediatric referral center for G-J tube placement.

Documentation in Patient #11's record and on the adverse event form dated 12/24/2013 at 9:09 pm states "G-J tube with extensions severed at the y port." Patient #11's medical record and adverse event form were reviewed on February 5, 2014 and February 6, 2014. Documentation in the medical record reveals the G-J tube was "patent" at 7:20 pm. Documentation in the nursing note dated 12/24/2014 at 9:09 pm states "G-J tube with extensions severed at the y port." Documentation by Staff #16 indicates the charge nurse on another floor and the nursing supervisor were notified at 9:09 pm on 12/24/2013. Staff #16 notifed the medical doctor at 9:20 pm on 12/24/2013. Patient #11 was unable to receive hydration or medications due to G-J tube being "severed at the y port. On 12/25/2013 at 6:30 am Staff #16 was called to Patient #11's bedside "as patient not ventilating." Documentation on the adverse event form reports the patient being ventilated manually with 100 percent oxygen. Documentation on the adverse event form dated 12/25/2013 states "patient had not received medications via G-J tube since 8:00 pm the night of the 24th." The adverse event report documentation dated 12/25/2013 reports the G-J tube "torn and taped non functiional for several days." Medical doctor was notified and Patient #11 was transferred to the local pediatric referral center. Staff #16 verified no registered nurse was physically present on the Pediatric Unit the dates night shift of 12/24/2013. Two Medical Facilities Inspectors interviewed Staff #16 by phone on 02/05/2014 at 1:10 pm. Staff #16 verified the findings in Patient #11's medical record. Staff #16 reported being told by Staff #18 to "try harder to get G-J tubes unclogged." Staff #16 reported Staff #18 has "pulled and milked G-J tubes" in an attempt to get the tube unclogged.

Documentation in Patient #13's record and on the adverse event form dated 08/10/2013 at 9:50 pm states "G-J tube broken at the port." Medications had been documented as given at 8:30 pm on 08/10/2013. Patient #13's medical record and adverse event form were reviewed on February 5, 2014 and February 6, 2014. Staff #19 was assigned to the patient. Patient #13 was sent to the local pediatric referral center for G-J tube replacement.

Documentation in Patient #13's medical record and on the adverse event form at 6:15 pm and dated 09/11/2013 states "unable to unclog J port." It was noted on the adverse event form dated 09/11/2013 documented by the nurse "discontinued attempts to flush when ballooning of tube near the y port was noted." It was noted on the adverse event form "clogged J port and sent nurses from the third floor but attempts were unsuccessful." Patient #13 was sent out to the local pediatric referral center for G-J tube replacement.

3) Documentation on the adverse event form dated 06/14/2013 at 10:15 pm for Patient #21 reported Patient #21 was observed to have the suction catheter attached to the "right cheek with the suction on." Documentation of the cheek being "red." Patient #21 would be unable to remove the suction from behind his/her ear.

Documentation on the adverse event form dated 06/14/2013 at 10:10 pm for Patient #20 indicates Patient #20 was observed to have the suction catheter attached "behind the right ear with the suction turned on." Patient #20 would be unable to remove the suction from his/her cheek.

4) Patient #1 has a Bivona #6 Tracheotomy Tube (tube inserted into the neck to facilitate breathing) with a cuff. Patient #1 receives oxygen twenty eight (28) percent via a trach (tracheostomy) collar. On 11/26/2013 Patient #1 was found with the "pilot balloon missing at 1:10 am." Documentation by the respiratory therapist indicates the pilot balloon was noted as present on the trach (tracheostomy) at 7:50 pm. Documentation in the clinical record on the nursing notes dated 11/ 25/2013 by Staff #16 indicates the trach was intact at 7:25 pm. Documentation in the clinical record of Patient #1 indicates the certified nursing assistant found Patient #1's trach without a balloon. The balloon was noted to be missing close to the trach site. She/he summoned Staff #16 to the bedside at 1:30 am on 11/26/2013. Patient #1 was noted not to be in any respiratory distress. Two respiratory therapists replaced the Bivona #6 tracheostomy tube. While on the unit from 02/03/2014 through 02/07/2014 Patient #1 was never observed moving. Patient #1's arms are noted to be contracted with his/her fists clenched.
Staff #17 was interviewed on 02/05/2014 at 2:10 pm. Staff #17 indicated he/she had asked Staff #16 if he/she had been doing trach care on Patient #1 and "accidentally cut the balloon while doing the trach ties." Staff #17 reported Staff #16 replied no. Staff #17 verified Patient #1 does not move. Staff #17 stated patient #1's "arms could not move up to tracheostomy." Staff #17 verified he/she was present on two occasions when balloons were missing from pediatric patient's trachs. Staff #17 verified the staff looked "everywhere for the balloon." Staff #17 verified the balloon missing from the trach was "unusual."
Staff #16 was interviewed on 02/04/2014 at 2:00 pm by two Medical Facilities Inspectors. Staff #16 verified he/she was caring for Patient #1 on 11/26/2013 when the balloon was missing from the trach site. Staff #16 verified Patient #1 does not move and both arms are contracted. Staff #16 verified Staff #17, Staff #9, and Staff #22 all looked in the bed, the trash, and on the floor for the balloon. Staff #16 indicated Staff #18 did not assist in looking for the trach balloon. No documentation on the adverse event report or in the nursing notes indicates the medical doctor was notified. Staff #16 verified the medical doctor was not notified the pilot balloon was missing from the trach. Patient #1 is in POD #1 of the Pediatric Unit.

Patient #6 has a Shiley #7 extra long (XLT) with a cuff. At the time of the incident the patient had a Bivona #6 trach. Patient #6 requires ventilator support. On 12/02/2013 the respiratory therapist was called to the patient's bedside by the certified nursing assistant at approximately 5:55 am. Patient #6 was found to "be missing the pilot balloon." Patient #6 was noted to have an oxygen saturation of one hundred (100) percent with a heart rate of one hundred forty three (143). A Bivona #6 was reinserted by the respiratory therapist with minimal bleeding noted at the trach site. No documentation was found on the adverse event report or in the clinical record that the medical doctor was notified. Patient #6 was not observed moving while on the pediatric unit on February 3, 2014 through February 7, 2014. Patient #6 is in POD 2 of the Pediatric Unit.

Patient #4 has a Bivona #4 Tracheotomy Tube with a cuff. The patient is off the ventilator for twelve (12) to eighteen hours (18) per day. Patient #4 receives ventilator support at night. On or about the day shift of 12/12/2013 Patient #4 was noted to have pulled the balloon off his/her trach and was found with the balloon in his/her hand according to documentation on the adverse event form dated 12/12/2013 by Staff #17. Patient #4 was noted not to be in any respiratory distress. No documentation was found in the nursing notes of Patient #4 pulling the balloon off the trach on the day shift of 12/12/2013. Documentation at 8:30 pm in the nurses notes reads the patient "was disconnected from the tubing times one while wrapping self in the tubing." Further documentation indicates the "trach and ventilator were intact." Documentation on the nursing note dated 12/12/2013 at 11:00 pm indicates the nurse received report from Staff #17 reporting the balloon had been torn off on the day shift by Patient #4. Documentation at 12:00 am by the nursing staff states "respiratory therapy will monitor for respiratory sufficiency." Further documentation on the adverse event report dated 12/12/2013 indicates the tracheostomy tube was not changed per verbal order of Staff #6 (Staff #6 is not a medical doctor). The adverse event form dated 12/12/2013 indicated Staff #6 instructed the "day respiratory staff not to change the trach until the scheduled day of 12/17/2013 if the patient is stable on the vent with the cuff deflated." The adverse event form was signed by both Staff #17 and Staff #6. No documentation was found that Patient #4's medical doctor was notified of the incident. Patient #4 was observed to be active and moving upper extremities while on the pediatric unit on 02/03/2014 through 02/07/2014. Staff #17 verified the findings during interview. Staff #6 was interviewed on February 4, 2014. Staff #6 verified the respiratory staff receives telephone orders. Staff #6 when asked what the hospital policy related to telephone and verbal orders stated "do not know." Staff #36 confirmed the hospital policy does not include that respiratory therapists can receive verbal or telephone orders. The hospital policy was received and reviewed on 02/06/2014.

Patient #1 has a #6 Bivona Trachesostomy Tube with a cuff. Patient #1 receives oxygen twenty eight (28) percent via a trach collar. Documentation by Staff #16 at 10:00 pm and 12:00 am on 12/13/2013 indicates the "trach was intact with the balloon in place." On 12/14/2013 at 1:00 am Patient #1 was found by Staff #16 "with the pilot balloon missing." Patient #1 was noted not to be in any respiratory distress. The trach was replaced by two respiratory therapists. While on the unit from 02/03/2014 through 02/07/2014 Patient #1 was never observed moving. Patient #1 is noted to have contracted arms with fists clenched. No documentation was found that a medical doctor was notified. Staff #16 was interviewed by phone at approximately 2:00 pm February 5, 2014. Staff #16 was interviewed in person at 2:00 pm on February 11, 2014. Staff #16 verified he/she was the nurse caring for patient #1 on 12/14/2014. Staff #16 verified Staff #9 and Staff #22 work in pairs to perform care on the pediatric patients during the night shift. This care includes turning the patients with two staff members present. Staff #16 verified in both episodes with Patient #1's trach balloon missing that Staff #22 and Staff #9 had searched for the balloon. Staff #16 indicated the staff had looked in the trash, in the bed, and the bed linens. Staff #16 confirmed the staff from respiratory therapy had assisted with looking for the balloon. Staff #16 confirmed no balloon was found. Staff #16 confirmed the balloon was missing from "the base of the trach." Staff #16 confirmed Staff #18 did not look for the balloon. Staff #16 stated "unusual to have the balloons missing." When asked what the word "sever" meant Staff #16 stated "cut." Staff #11 was interviewed on 02/05/2014 at approximately 2:45 pm. Staff #11 verified the balloon on Patient #1's trach appeared to have been "cut." Staff #11 indicated he/she thought the balloon was "cut" deliberately. Staff #11 verified he/she has "never seen so many balloons missing." Staff #11 was asked to define sever and stated "it means to cut." Staff #18 was interviewed on February 5, 2013 at 3:15 pm. Staff #18 confirmed he/she was present on the unit 12/13/2013 through 12/14/2013. Staff #18 stated "it is unusual to have balloons missing. It does not happen every day." Staff #18 confirmed he/she did not assist in looking for Patient #1's trach balloon. Staff #16 and Staff #18 confirmed no medical doctor was notified. Staff #6 was interviewed on February 4, 2014. Staff #6 stated "balloon on Patient #1's trach was missing at the base of the trach and this finding sent a red flag." Staff #6 indicated it was "unusual to have balloons missing but thought it was due to the balloons being torn off during turning." Staff #6 was interviewed again on February 4, 2014 and confirmed Patient #1 was the patient who had the balloon missing at the base.

Patient #5 has a #6 Bivona Trachesostomy Tube with a cuff. The cuff remains deflated. Patient #5 receives twenty eight (28) percent oxygen via a trach collar. On 12/28/2013 at approximately 3:00 am Staff #11 was called to Patient #5's bedside by Staff #22 and a respiratory therapist. Patient #5 was noted not to be in any respiratory distress. Documentation on the adverse event report dated 12/28/2013 reads "the pilot balloon was severed at the base" of the trach. No further documentation of the event was noted in the medical record of Patient #5. No documentation was found the medical doctor was notified of the event. Staff # 11 was interviewed on February 5, 2014. Staff #11 confirmed the findings on the adverse event report. Staff #11 confirmed Staff #22, Staff #16, and Staff #9 all searched for the balloon. Staff #16 verified Staff #18 did not help search for the balloon. Staff #6 was interviewed for a third time on February 11, 2014. Staff #6 denied the balloon on Patient #5's trach had been "severed at the base." Staff #6 indicated the balloon was missing at the site "close to the trach not at the base of the trach."

Staff #12 was interviewed by phone on 02/04/2014 in the first floor conference room by two Medical Facilities Inspectors. Staff #12 stated "did not know about the trachs with the missing balloons on the pediatric floor." Staff #12 stated "it is unusual." Staff #38 was interviewed by phone by two Medical Facilities Inspectors on 02/05/2014 at approximately 2:15 pm. Staff #38 reported he/she had no prior knowledge of the multiple incidents of pilot balloon detachments on the Pediatric Unit. Staff #38 reported "made aware yesterday." Staff #38 reported he/she had no prior knowledge of of the multiple incidents of G-J tubes being reported as "severed at the y port." Staff #38 stated sever "means to cut."
Staff #6 was interviewed for a third time on the afternoon of February 11, 2014. Staff #36 was present at the interview in the first floor conference room. Staff #6 confirmed the tracheostomy tube "severed at the base" belonged to Patient #1. Staff #6 verified the tracheostomy tube in the clear plastic bag which the facility had saved is Patient #1's.

5) Staff #2 was observed touching Patient #8 on February 5, 2014 at 12:00 pm on or about the neck without washing hands prior to touching Patient #8. Staff #7 and Staff #33 were observed on February 10, 2014 at approximately 7:25 pm touching Patient #12 without washing hands. Staff #7 was observed touching Patient #2 without washing hands on February 10, 2014 at approximately 7:30 pm. Staff #21 was observed passing medications on 02/06/2014 at approximately 9:15 am by one Medical Facilities Inspector. Staff #21 was observed not washing hands prior to donning gloves. The facility's policy on Administration of Medications states "hands must be washed" prior to administering medications.
Staff #36 was made aware of findings on 02/12/2014 at approximately 1:00 pm.

6) Documentation review on February 6, 2014 and February 11, 2014 revealed ten unplanned tracheostomy decannualations (the removal of a tracheostomy tube) on the Pediatric Unit. Each time the decannulation occurs the patient must have the tracheostomy tube replaced. Seven of the ten unplanned decannulations occurred on the night shift according to the documentation provided to the surveyor. Patient #8 had four unplanned decannulations. Patient #8 was observed on the unit multiple times during the survey the week of February 3, 2014. Patient #8 was observed moving arms around and attempting to pull at trach site on 02/05/2014 at approximately 11:45 am by one Medical Facilities Inspector. Documentation on the adverse event form dated 08/11/2013 reports Patient #8 self decannulated while at the nurses station. Documentation on the adverse event form dated 11/01/2013 reports the "trach was found out" by the team leader and the certified nursing assistant. Documentation on the adverse event form dated 11/03/2013 reports Patient #8 was found by the certified nursing assistant with the "trach out." Documentation on the adverse event form dated 11/26/2013 reports the "certified nursing assistant found the patient with the trach out of neck with the trach ties still fastened." Documentation on the adverse event report form dated 06/10/2013 for Patient #3 indicates Patient #3 decannulated due to the "ventilator tubing caught on the rail." Patient #4 documentation on the adverse event report dated 07/18/2013 reported Patient #4 decannulated "self." Patient #4 documentation on the adverse event form dated 11/01/2013 reports Patient #4 decannulated due to being "wrapped around the circuit." The documentation reports Patient #4's oxygen saturation as "80 percent during the decannualtion." Documentation on the adverse event form dated 11/03/2013 on Patient #9 reports the patient "coughed the trach tube out." The decannulations reported on the day shift occurred due to "trach circuit" caught on the siderail.
Staff #35 was interviewed by phone on 02/11/2014 at 3:40 pm by two Medical Facilities Inspectors in the first floor conference room. Staff #35 confirmed ten decannulations in a 5 month period seemed high. Staff #35 stated "one or two might be expected." Surveyor unable to review statistics on decannualtions for the year 2012. Staff #36 unable to provide adverse event forms for 2012 when asked on February 11, 2014 at approximately 8:30 am. Staff #36 reported all adverse event forms for 2012 have been purged.

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Based on document reviews and interviews the facility failed to monitor and include patient safety data into the Quality Assessment and Performance Improvement Program.

The findings included:

Quality Assessment and Performance data including the minutes from the QAPI Quarterly Meeting were obtained the week of February 3, 2014. The meeting minutes were reviewed on February 10, 2014 at approximately 4:45 pm. No data was found in the QAPI meeting minutes related to the incidence of detached and missing pilot balloons on patients in the Pediatric Unit. No data was found reporting the incidents of G-J tubes "severed at the y port." Staff #36 verified this finding the afternoon of 02/07/2014.

Based on document reviews and interviews the facility failed to identify the activities of the quality improvement program.

The findings included:

Quality Assessment and Performance data including the minutes from the QAPI Quarterly Meeting were obtained the week of February 3, 2014. The meeting minutes were reviewed on February 10, 2014 at approximately 4:45 pm. No data was found in the QAPI meeting minutes related to the incidence of detached and missing pilot balloons on patients in the Pediatric Unit. No data was found reporting the incidents of G-J tubes "severed at the y port." No data was found relating to the incidents of the suction catheters being attached to two patients on the pediatric unit. No documentation of the ten decannulations on the Pediatric Unit being included in the hospital's QAPI Program. Staff #36 verified this finding the afternoon of 02/07/2014.

Based on document reviews and interviews the facility failed to set priorities that focused on high-risk, high volume, or problem prone areas.

The findings included:

Quality Assessment and Performance data including the minutes from the QAPI Quarterly Meeting were obtained the week of February 3, 2014. The meeting minutes were reviewed on February 10, 2014 at approximately 4:45 pm. No data was found in the QAPI meeting minutes related to the incidence of detached and missing pilot balloons on patients in the Pediatric Unit. No data was found reporting the incidents of G-J tubes "severed at the y port." Staff #36 verified this finding the afternoon of 02/07/2014.

Based on document reviews and interviews the facility failed to ensure a registered nurse be immediately available for the bedside care of any patient.

The findings included:

The facility's Pediatric Unit nursing staffing schedules were reviewed on February 6, 2014 and February 10, 2014 by one Medical Facilities Inspector. The months of December 2013, January 2014, and February 2014 were reviewed. The average daily census in the Pediatric Unit is twenty. The weeks of the survey the unit had 13 ventilator patients and 7 trachesostomy patients. The following was found during the review:

No registered nurse was physically present on the Pediatric Unit the following night shift dates.

1. On 12/09/2013 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit.

2. On 12/24/2013 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit.

3. On 01/30/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit. One of the licensed practical nurses was reassigned from the Adult Unit.

4. On 01/10/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit. One of the licensed practical nurses was reassigned from the Adult Unit.

5. On 01/15/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit. Both licensed practical nurses were reassigned from the Adult Unit.

6. On 01/20/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit.

7. On 01/21/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit.

8. On 02/03/2014 two licensed practical nurses and two certified nursing assistants were present on the Pediatric Unit.

A phone interview was conducted with Staff #16 on 02/05/2014 at approximately 1:15 pm by two Medical Facilities Inspectors. Staff #16 confirmed the Pediatric Unit often does not have a registered nurse physically present on the unit. Staff #16 reported he/she "gets the charge nurse from 2 east or the nursing supervisor." Staff #16 was interviewed a second time on 02/11/2014 at approximately 2:00 pm in the conference room by two Medical Facilities Inspectors. Staff #16 confirmed he/she was caring for Patient #9 on 12/09/2014. Patient #9 had a diagnosis of mental retardation, seizures, tracheostomy, gastrostomy, and a history of deep vein thrombosis. Patient #9 had a do not resuscitate order. Staff #16 verified the staffing on 12/09/2014 included two licensed practical nurses and two certified nursing assistants. Staff #16 reported there was no registered nurse physically present on the unit the night of 12/09/2013. Staff #16 was provided Patient #9's medical record. Staff #16 verified the nursing note written on 12/09/2013 reported Patient #9's heart rate of 148 upon initial assessment documented by Staff #16 at 7:20 pm. Staff #16 reported "148 was not a normal heartrate" for Patient #9. Staff #16 confirmed the nursing note reported Patient #9 had a "slightly distended abdomen and no residuals." Staff #16 reported he/she thought Patient 9's elevated heartrate was due to pain although Patient #9 had been medicated for pain approximately two hours prior to the initial assessment.
Staff #16 verified at 11:15 pm he/she was called to Patient #9's bedside by a respiratory therapist and two certified nursing assistants. Staff #16 verified the documentation in the clinical record reported Patient #9 was SOB (short of breath) and using accessory muscles. Staff #16 verified he/she had been told Patient #9 had bitten lip. Staff #16 stated "we thought the patient had a seizure." The facility policy #8.21 Seizure Document was received on 02/06/2014 at 3:10 pm. Under section three the policy states "notify MD (medical doctor) of change in patient condition." Staff #16 verified the medical doctor was not notified at 11:15 pm. Staff #16 verified documentation in Patient #9's medical record stated "abdomen extremely distended. Patient had bowel movement. Residual 700 cc of light brown colored liquid. Bowel sounds unable to hear." Documentation in Patient #9's clinical record indicates the nursing supervisor was at Patient #9's bedside at 11:30 pm. Staff #16 reported the staff repositioned Patient #9. Staff #16 confirmed the medical doctor was not called to notify of the change in Patient #9.
Staff #16 verified documentation in Patient #9's medical record reports a change in breathing noted by Staff #16 at 1:15 am. Staff #16 stated he/she "could not remember whether he/she went for the registered nurse on 2 east or sent the other licensed practical nurse." Documentation on the nursing note dated 12/10/13 indicates the registered nurse arrived at Patient #9's bedside at 1:25 am. Nursing documentation for the same time indicates Patient #9 had no heartrate and pupils were fixed and dilated. Patient #9 was pronounced dead at 1:30 am. The first call to the medical doctor regarding Patient #9 was placed at 1:35 am. Staff #16 confirmed the medical doctor was never called about the change in Patient #9's condition. Staff #16 verified it is not unusual to not have a registered nurse physically on the Pediatric Unit at night.

Documentation in Patient #11's medical record and on the adverse event form dated 12/24/2013 at 9:09 pm states "G-J tube with extensions severed at the y port." Patient #11's medical record and adverse event form were reviewed on February 5, 2014 and February 6, 2014. Documentation in the medical record dated 12/24/2013 reports the G-J tube was "patent" at 7:20 pm. Documentation in the nursing note dated 12/24/2013 at 9:09 pm states "G-J tube with extensions severed at the y port." Documentation by Staff #16 reports the charge nurse on another floor and the nursing supervisor were notified at 9:09 pm on 12/24/2013. Staff #16 notified the medical doctor at 9:20 pm on 12/24/2013. Patient #11 was unable to receive hydration, nutrition, or medications due to the G-J tube being "severed" at the y port.
On 12/25/2013 at 6:30 am Staff #16 was called to the Patient 11's bedside "as patient not ventilating." Documentation on the adverse event report dated 12/25/2013 reports Patient #11 was being manually (by ambu bag) ventilated with 100 percent oxygen. Documentation on the adverse event report dated 12/25/2013 states "patient had not received medications via G-J tube since 8:00 pm the night of the 24th." The adverse event report documentation dated 12/25/2013 reports the G-J tube "torn and taped and non-functional for several days." Staff #16 notified medical doctor and Patient #11 was transported to the local pediatric referral center.
Staff #16 verified no registered nurse was scheduled to work on the Pediatric Unit the night of 12/24/2013. Two Medical Facilities Inspectors interviewed Staff #16 by phone on 02/05/2014 at 1:10 pm. Staff #16 verified the findings in Patient #11's medical record. Staff #16 reported being told in the past by Staff #18 to "try harder to get the G-J tubes unclogged." Staff #16 reported Staff #18 has "pulled and milked G-J tubes" in an attempt to get the tube unclogged.
Staffing schedules were reviewed on 02/15/2014 at 1:30 pm. Two licensed practical nurses were scheduled to work the night shift of 12/24/2013.

Based on document reviews and interviews the facility failed to ensure the registered nurse supervise and evaluate the nursing care for twenty of twenty pediatric patients (Patients #1-#20).

The findings included:

Staff #36 documented in an undated letter provided to the survey team on 02/06/2014 he/she thought one certified nursing assistant felt he/she could care for the children. Staff #36 reported he/she felt the certified nursing assistant had not followed the hospital policy on turning patients. Staff #36 reported Staff did not follow the policy. The letter provided states "did not follow the policy of using two staff to turn/reposition these dependent children, resulting in accidental pilot balloon detachment." Staff #36 was interviewed multiple times during the complaint survey. Staff #36 was interviewed on February 4, 2014 at approximately 9:00 am. Staff #36 reported he/she felt the balloons detached from the tracheostomy tubes due to the one staff member turning the patients. Staff #36 confirmed there is not always a registered nurse to supervise the nursing care of the pediatric patients.

Staffing schedules for the Pediatric Unit were reviewed on February 6, 2014 and February 10, 2014 by one Medical Facilities Inspector. The months of December 2013, January 2014, and February 2014 were reviewed. On eight night shifts there is no registered nurse scheduled in the pediatric unit.

Seven of twenty clinical records reviewed on the Pediatric Unit on 02/07/2014 at 9:30 am had unsigned verbal orders. All twenty clinical records reviewed had verbal orders.

The findings included:

The verbal orders found in the clinical records on the Pediatric Unit were given by Staff #12 by telephone. Four of the seven order sheets found with unsigned verbal orders were related to medication orders. The facility policy on verbal orders indicates verbal orders will be taken in "an emergency" by a registered nurse or licensed practical nurse. One order found on Patient #7 was taken by Staff #6 from Staff #12 on 01/15/2014. Staff #6 is prohibited from taking verbal orders per the hospital policy. The hospital policy is titled "Interim/Telephone Physcian Order" sheets last reviewed on 11/13. Verbal orders are only to be taken by a registered nurse or licensed practical nurse. The order is unsigned by Staff #12. Staff #12 was interviewed a second time by two Medical Facilities Inspectors by phone on 02/07/2014 at approximately 10:45 am. Staff #12 recalled giving Staff #6 the phone order on 01/15/2014 to change Patient #7's ventilator settings. Staff #12 did not recall canceling the order. Documentation on the ventilator flow sheet reports the ventilator change was made at approximately 9:15 am. Staff #6 did not document the order until 3:15 pm. The order was discontinued by Staff #6 at the same time the order was written on 01/15/2014. Staff #12 stated "do not know the policy on verbal orders." Staff #12 reported he/she does not give that many orders. The facility policy on verbal orders titled "Interim/Telephone Physician Order" sheets (Policy # 9.2) states "the order must be signed by the nurse and countersigned by the physcian within 24 hours on the hospital level."

Staff #12 was interviewed by phone on 02/04/2014 at 10:23 am by two Medical Facilities Inspectors in the first floor conference room. Staff #12 verified he/she makes rounds on the Pediatric Unit once a week.

Based on document reviews and interviews hospital staff failed to follow the hospital policy related to verbal orders.

The findings included:

Twenty clinical records were reviewed on the Pediatric Unit by two Medical Facilities Inspectors for verbal orders on 02/07/2014 at 9:30 am. Staff #2 was present during the review. One verbal order (telephone order) was found on Patient #7's medical record dated 01/15/2014. The order was written by Staff #6 who is not authorized per the hospital policy to receive telephone/verbal orders The hospital policy related to verbal orders was received between 02/03/2014 and 02/07/2014. The policy is titled "Interim/Telephone Physician Order Sheets." Documentation on the ventilator flow sheet reported the change on the ventilator was made at 9:15 am on 01/15/2014. Staff #6 documented the order in Patient #7's medical record at 3:15 pm on 01/15/2014. The order was discontinued the same time the order was written on 01/15/2014. The order was not cosigned by Staff #12. Staff #12 was interviewed for a second time by phone by two Medical Facilities Inspectors on 02/07/2014 at approximately 2:45 pm. Staff #12 verified the order was given to Staff #6. Staff #12 reported he/she did not recall discontinuing the order. Staff #6 was interviewed for a second time on 02/07/2014 at 1:30 pm by two Medical Facilities Inspectors in the first floor conference room. Staff #6 confirmed he/she wrote the verbal order on Patient #7 on 01/15/2014. Staff #6 confirmed he/she instructed the respiratory therapist to make the ventilator change on Patient #7. Staff #6 verified the order was written in Patient #7's medical record at 3:15 pm on 01/15/2015. Staff #6 verified the order was written and discontinued at the same time. When asked if Staff #6 knew the policy on verbal orders he/she stated "never seen a policy here." Staff #36 was asked on February 7, 2014 who could take verbal orders and stated "only registered nurses and licensed practical nurses."

Based on observations, documentation, and interviews the facility failed to maintain a safe environment for twenty of twenty pediatric patients (Patient #1-#20).

The findings included:

Two Medical Facilities Inspectors entered the facility unnoticed at approximately 7:00 pm on February 10, 2014. Entrance was made through an unsecured and unmonitored front entrance (not the main front entrance). The two Medical Facilities Inspectors were able to walk through the halls of the facility and gain access into the Pediatric Unit. Once on the Pediatric Unit the nursing staff was aware of the two Medical Facilities Inspectors. Staff #32 arrived on the unit at approximately 7:10 pm.

An interview was conducted with Staff #27 on the afternoon of February 6, 2014 by two Medical Facilities Inspectors in the first floor conference room. Staff #27 confirmed the hospital has security cameras. Staff #27 confirmed the security cameras are not always being observed by security. Staff #27 reported the security checks can take up to an hour and after the operator leaves at 12:00 am no hospital staff would be watching the hospital security cameras during the routine security checks. Staff #27 verified the pediatric unit has a camera at the entrance of the unit. Staff #27 verified if on routine checks no one would be watching the camera. Staff #27 confirmed the pediatric unit could be accessed unnoticed.
Staff #18 was interviewed on 02/05/2014 by two Medical Facilities Inspectors at approximately 3:15 pm in the first floor conference room. Staff #18 reported other night staff from other areas in the hospital come for coffee on the Pediatric Unit. Staff #18 confirmed POD 1 is the area in the Pediatric Unit where most of the detached and missing pilot balloons adverse events have occurred. Staff #18 confirmed POD 1 is closest to the entrance to the Pediatric Unit. Staff #18 confirmed there could be a time when all staff were busy caring for patients in another POD and someone could enter the unit unnoticed.

Based on observations the facility failed to ensure an acceptable level of safety and quality by not performing routine preventative maintenance on nine of thirteen ventilators on the pediatric unit.

The findings included:

On 02/04/2014 at approximately 8:00 pm thirteen ventilators were checked for documentation of routine preventative maintenance. Nine of thirteen ventilators viewed were overdue for preventative maintenance. Five ventilators were due for maintenance April 2013. One ventilator was due for maintenance June 2013. Two ventilators were due for maintenance July 2013. One ventilator was due for maintenance August 2013. Staff #2 was present during the findings. Staff #36 confirmed the facility has no policy on preventative maintenance of equipment on 02/12/2014 at approximately 8:00 am.

Based on observations and interviews the facility failed to follow policies governing infection control.

The findings included:

1) A medication pass was observed on the Pediatric Unit on February 6, 2014 at approximately 9:15 am by one Medical Facilities Inspector. Staff #21 failed to wash hands prior to donning gloves.

2) Staff #2 was observed touching Patient #8 on or about the neck at approximately 12:00 pm on February 5, 2014 by one Medical Facilities Inspector on the Pediatric Unit. Staff #2 did not wash hands or put on gloves prior to touching Patient #8.

3) On February 10, 2014 at approximately 7:25 pm one Medical Facilities Inspector observed Staff #7 and Staff #33 touching Patient #12 without washing hands on the Pediatric Unit. Staff #33 was observed using hand sanitizer after touching Patient #12. Staff #7 was observed touching Patient #2 without washing hands or using hand sanitizer on February 10, 2014 at approximately 7:30 pm on the Pediatric Unit.

4) Twenty of twenty suction canisters in use were observed not dated on February 4, 2014 at approximately 12:00 pm by two Medical Facilities Inspectors on the Pediatric Unit. Staff #26 was interviewed on 02/06/2014 at approximately 4:40 pm. Staff #26 verified the nursing staff do not always date and time the suction canisters. Staff #26 reported he/she has asked the staff on the Pediatric Unit to date and time the suction canisters to decrease the chance of infection. Staff #7 was interviewed by two Medical Facilities Inspectors on 02/04/2014 at approximately 4:30 pm. Staff #7 reported suction canisters are changed every Monday, Wednesday, and Friday. Staff #7 denied dumping the contents of the suction canisters into a sink. Staff #22 was interviewed by phone on 02/06/2014 at approximately 12:30 pm by two Medical Facilities Inspectors. Staff #22 stated "I date the suction canisters." Staff #22 stated "one canister not changed for a month." Staff #22 stated "Staff #26 said do not date the suction canisters."

5) Nine of twenty tube feeding bags were observed unlabeled and or dated on February 14, at approximately 12:00 pm by two Medical Facilities Inspectors on the Pediatric Unit. Three of thirteen ventilator or trach humidification sterile water bottles were observed with no time or date. The facility policy (Policy 7.22) on tube feedings under section three states "containers are to be labeled with the date/time initiated." Staff #2 was present during the findings.

6) Two (Patient #6 and Patient 11) of twenty patients observed on the Pediatric Unit during the initial visit to the unit on February 3, 2014 at approximately 11:40 am by two Medical Facilities Inspectors were found to have the need for mouth care. Patient #6's mouth had crusting on it. Patient #11 was observed to have copious oral secretions draining from the mouth. Staff #5 reported oral care provided once a shift and as needed. Policy 7.27 titled Oral Care was received on February 5, 2014. The facility's Oral Care Policy states "ventilated and tracheostomy patients will be provided oral care twice per shift. Staff #2 was present during the findings.