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Based upon reviews of personnel files (S11), medical records, policies/procedures, and staff interviews, the Director of Nursing (DON) failed to ensure all patients (#11) who received medication/s were administered those medications in accordance with approved policies/procedures and standards of care as evidenced by a patient (#11) who received the wrong medication. Findings:

Review of the personnel file for S11 Licensed Practical Nurse (LPN) revealed a photocopy of a bag of intravenous fluids (IVF) with a pharmacy label that indicated the 500 milliliter (mL) bag of 0.9% Sodium Chloride (NS) had Vancomycin (antibiotic) HCL 1000 mg (milligrams)-2200 mg total. Further review of the photocopy revealed the 0.9% Sodium Chloride with the added Vancomycin was labeled with patient #12's name; however, it was found that patient #11 had received this medication/IVF.

Continued review of the photocopy revealed "4/22/11 @ 2000 (8PM) This was found hanging on 620A (name of patient #11) @ 20 mL/hr. It should be 3% NS (normal saline) hanging @ 20mL/hr." There failed to be a documented signature of the individual who wrote this note. Interview, 09/08/2011 at 2:00PM, with S3 DON revealed he was unable to recognize the handwriting on the note.

Review of patient #11's Medication Administration Record (MAR), dated 04/22/2011 6 AM through 04/23/2011 5:59 AM, revealed S11 LPN documented her initials and placed a line through the time 1649 (4:49 PM) that indicated she had placed another IVF bag of 3% Sodium Chloride on patient #11. However, as indicated in the above paragraph, patient #11 received a 500 mL bag of 0.9% Sodium Chloride with Vancomycin 2200mg added instead of the 3% Sodium Chloride.

Review of policy number C20:02:01, titled "Medication Administration", revealed: "Purpose: ...To establish guidelines for administering medications...Policy: Administration of Medications...4. Prior to medication administration, the nurse shall check the MAR against the physician's orders, ensure that the correct medication has been selected based on the medication order and label, ...5. At the patient's bedside, verify the patient's name and hospital ID number on the MAR and the patient's armband...The nurse shall use the seven rights of medication administration including: the right patient, the right medication, the right dose, the right route, the right to refuse, and the right to be educated..."

Review of policy number A30:02:03, titled "Standards of Care", revealed: "...The nurse will...1.1.3 Ensure that equipment and supplies will:...E. Be appropriately identified including:...2. All intravenous solutions with or without additives..."

Interviews, on 09/08/2011 at 2:10PM, with S2 Registered Nurse Quality Assurance and S3 DON confirmed S11 LPN failed to follow established policies and procedures for medication administration as evidenced by the wrong medication administered to patient #11.

Based upon review of 6 of 19 open and closed medical records (#1, #14, #15, #17, #18, #19) and staff interviews, the hospital failed to ensure each patient's medical record contained complete documentation related to physician orders (#1, #17, #18), evaluations, treatments, and interventions provided to the patient during hospitalizations at different hospitals (#1, #14, #15, #17, #18, #19). Findings:

1. Review of the medical record for patient #1 revealed the patient was admitted on 05/31/11 with the diagnoses of pneumonia, status post left below the knee amputation, sacral wound and sepsis. Review of the nursing notes dated 06/03/11, 11:45 AM, revealed "Notified of patient admit to (Hospital D)". Review of the physician order sheets for 06/03/11 revealed there failed to be an order from a physician to admit the patient to Hospital D. Further review of the nursing notes revealed on 06/08/11, 7:30 PM "Returned to facility from LOA (Leave Of Absence), S/P (Status Post) Left AKA (Above the Knee Amputation), staples intact..." Review of the physician progress notes revealed the medical record failed to contain documentation related to the treatment and interventions provided to patient #1 during the 5 day hospitalization at Hospital D.

2. Review of patient #14's medical record revealed the patient was admitted to the hospital on 08/12/11 with the diagnosis of a diabetic foot ulcer. On 08/26/11, Physician S7 identified on a Discharge Summary and on the physician order sheet that patient #14 required admission to Hospital B for Orthopedic care and further debridement of the foot ulcer. On 9/02/11, the patient was re-admitted to Cornerstone Hospital; however, the medical record failed to contain documentation related to the treatment and interventions provided to Patient #14 during the 7 day hospitalization at Hospital B.

3. Review of the medical record for patient #15 revealed the patient was admitted on 06/14/11 and discharged to the nursing home on 08/04/11. Review of the physician orders revealed on 06/17/11, 7:00 AM, Physician S6 ordered "Transfer to (Hospital B) ICU" for respiratory failure. Further review of the physician orders revealed on 06/23/11, the patient was re-admitted to Cornerstone Hospital. The medical record failed to contain documentation related to the treatment and interventions provided to Patient #15 during the 6 day hospitalization at Hospital B.

4. Review of the medical record for patient #17 revealed the patient was admitted on 03/24/11 and discharged on 05/03/11. According to the Physician's Discharge Summary, the hospital course included the patient's need for Intravenous antibiotics and aggressive wound care. Physician S12 was consulted and recommended the patient be transferred to Hospital B for wound debridement, then return to Cornerstone for further wound care. The medical record failed to contain documentation related to physician orders to transfer/admit the patient to Hospital B, even though there were re-admission orders dated 04/19/11. The medical record failed to contain documentation related to the treatment and interventions provided to patient #17 while at Hospital B for 4 days.

5. Review of the medical record for patient #18 revealed the patient was admitted to the hospital on 04/07/11 with the diagnoses of multiple necrotic wounds and sepsis and discharged on 06/02/11. Review of Physician S6's Discharged Summary revealed the patient required admission to Hospital B for debridement of the necrotic wounds and "The patient had some bleeding after debridement, stayed in the ICU, form there, the patient was transferred back..." Review of the physician orders revealed there failed to be orders to transfer the patient to Hospital B. There also failed to be documentation by the physician related to the treatments and interventions provided to patient #18 during the 5 day stay at Hospital B.

6. Review of the medical record for patient #19 revealed the patient was admitted to the hospital on 07/22/11 with the diagnoses of ischemic ulcer right foot, status post amputation of toes, and end stage renal disease. Review of the physician orders revealed on 08/13/11 at 6:45 PM, "Transfer pt (patient) to (Hospital B) ICU (Intensive Care Unit)..." On 08/18/11 at 8:00 AM, the patient was re-admitted to Cornerstone Hospital. Review of the nursing notes dated 09/02/11 revealed at 12:25 PM, the patient was "...discharged to (Hospital B) per (Ambulance Company) stretcher. As of 09/06/11, the patient was still admitted to Hospital B. The medical record failed to contain documentation of the treatment and interventions provided to the patient while at Hospital B for 5 days (8/13/11 to 8/18/11) or why the patient required re-admission to Hospital B on 09/02/11.

Interview with the Hospital Administrator, S1, on 09/06/11 at 11:35 AM, revealed if the patient is transferred and admitted to another hospital and the stay at that hospital is 9 days or less, the patient is not discharged from Cornerstone but on a "Leave Of Absence". When a policy was requested for this procedure, S1 confirmed there was no policy that addressed the patient being on a "Leave of Absence" from the hospital.

Based upon observations, reviews of policies/procedures, personnel files and staff interviews, the facility failed to ensure all hospital staff followed Infection Control policies and procedures for contact precautions as evidenced by 1) surveyor observed Registered Nurse (RN S8) took patient's medical record into patient's room (Room 520) who had contact precautions posted and then placed the same medical record on top of the medication cart without disinfecting the medical record first; and 2) surveyor observed Respiratory Therapist (RT S9) come out of patient's room (Room 527), who had contact precautions posted, provided patient care without wearing personal protective equipment (PPE) as per policy and procedures. Findings:

The surveyor observed, on 09/07/2011 at 1030 AM, S8 RN gathered her stethoscope and the patient in Room 520's chart and then she entered Room 520. The door to Room 520 was posted with a sign that read "STOP Contact Precautions/Isolation Wear gloves when in the room Wear a gown when coming in contact with the patient or the patient's items or belongings." When S8 RN exited the room she had removed her gloves first, used alcohol rub for hand hygiene, then placed the medical record on top of the medication cart; however, she failed to disinfect the medical record first nor had she donned a gown while she examined the patient in Room 520. Review of Room 520 patient's medical record revealed she was admitted with MRSA (Methicillin Resistant Staph. Aureus) in the wound on her foot. S8 RN was interviewed, 09/07/2011 at 1:30PM, and stated she just forgot to wear the gown and further stated she had been instructed to always take the patient's medical record into the room when performing assessments. The surveyor questioned if this applied to patients who were in contact isolation/precautions, S8 RN did not respond.

The surveyor observed, on 09/07/2011 at 11:15AM, S9 Respiratory Therapist (RT) exited room 527. The door was also posted with the same Contact Isolation/Precautions sign as in the above paragraph. The surveyor and S2 RN Quality Assurance/Infection Control Nurse followed S9 RT back to the Respiratory Care department. S9 was questioned if he had utilized his PPE and then performed hand hygiene; he stated no. This was confirmed by S2 RN. Review of Room 527 patient's medical record revealed the patient was admitted with Klebsiella pneumonia and MDRO (Multiple Drug Resistant Organisms) in her urine. S9 RT stated he had just been in Room 527 and had removed the patient's breathing treatment and hung it up. S9 was questioned about the use of gloves when performing this procedure; however, no response was given. S9 RT later informed S2 RN that he had not worn PPE or performed hand hygiene per infection control policy and procedure.

Review of Infection Control policy #06:079:00 titled "Contact Precautions" revealed: "Policy Statement: To outline the use of Contact Precautions designed for patients infected or suspected to be infected with transmissible pathogens for which additional precautions (beyond Standard Precautions) are needed. Content:...I...D. A Contact Precaution Sign should be attached directly to patient room door. Do not remove sign until housekeeping has cleaned room. II. Protective Equipment: ...B. Gloves (clean, nonsterile) 1. should be worn by all persons entering the room...3. should be removed and hands hygiene performed prior to leaving the patient's room...C. Gowns (clean, nonsterile) 1. Should be worn by all persons entering the room..."

Review of a information sheet titled "Hand Hygiene Fact Sheet for Health Care Settings", revealed "In health care settings, hand hygiene is the single most important way to prevent infections. Hand hygiene is the responsibility of all individuals involved in health care...". Interview, 09/07/2011 at 1:00PM, with S2 RN Infection Control/Quality Assurance revealed this information sheet was maintained in the orientation binder and was part of the infection control education that all employees received.

Review of S8 RNs personnel file revealed she had received Infection Control training on 03/02/2011 and had attained a score of 100 out of 100.

Review of S9 RT personnel file revealed he had received Infection Control training on 10/2010 and was due for an annual update on 10/2011.

Interviews, 09/07/2011 at 3:45PM, with S2 RN Infection Control/Quality Assurance and S3 Director of Nursing/Chief Clinical Officer confirmed all personnel had received infection control training upon hire and annually thereafter; S2 further stated she frequently made observations of personnel to make certain they were following infection control policies as the patients the hospital received often have MRSA infections and other transmissible infections. S2 RN confirmed S8 RN and S9 RT did not follow hospital infection control policies and procedures relative to patients who were in contact isolation/precautions.