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Based on interview and record review the facility failed to provide written grievance solutions within a reasonable time frame to patients and/or families filing a complaint/grievance in four (#47, #48, #49, #52) of ten closed patient charts reviewed. This has the potential to affect all patients. The facility census was 92.

Findings included:

1. Review of the Patient Complaint/Grievance Policy dated 2/09 showed the following:
-Purpose of Policy: Establish a process for prompt and effective resolution of patient', families' and visitors' concerns and complaints/grievances.
-Customer Complaints/Grievances - Actions to Be Taken: CEO or designee must provide patient/family with a verbal or written progress report within 7 business days of receipt of complaint/grievance and maintain ongoing communication until point of resolution (not to exceed 30 days. The initial contact must include:
-statement acknowledging receipt of the complaint/grievance
-specific time frame when the patient/legal representative can expect conclusion/resolution to their expressed complaint/grievance.

2. Record review of the Complaint/Grievances' provided by the facility showed the following:

Record review of Patient #47's Complaint/Grievance was received by the facility on 03/01/11. The grievance alleged the following:
-the patient was allowed to fall while the student therapist was transferring the patient from a chair back to the bed resulting in an injury

-An e mail from a physician to Staff A, CEO, Staff B, Risk Manager and Staff Q, Director of Therapy Operations dated 03/11/11 stated that the physician had spoken with the spouse of the patient regarding his/her grievance and the spouse again asked for a written response from the facility.

-The "RESPONSE" section of Complaint/Grievance was dated 3/16 (no year) and stated that Staff B, Director of Quality/Risk Management had "called" to follow up with the spouse's requests from the physician. Further, the documentation states the spouse asks when a letter would be received. This documentation states a letter would be sent to the spouse by the end of March.

The record showed no documentation of a verbal or written response to the patient until 03/23/11 which was not within the seven day time frame.

3. Record review of Patient #48's Complaint/Grievance was received by the facility on 03/30/11.
-The grievance alleged the following:
-the patient did not receive his/her medications ordered for 5:00 PM on 03/29/11 until 7:00 PM
- requested a narcotic pain medication at 8:00 PM which was not received until 9:00 PM.
- the nurse did not observe him/her take the narcotic medication.
-the nurse almost gave twice the prescribed dosage of a medication

The record showed no documentation of a verbal or written response to the patient until 04/28/11 which was not within the seven day time frame.

4. Record review of Patient #49's Complaint/Grievance was received by the facility on 04/06/11.
-The grievance alleged the following:
- the CPAP (Continuous positive airway pressure)[a method of respiratory ventilation] mask was not placed properly (on upside down)
-the nasal cannula of the oxygen was placed in the nose but the oxygen was not turned on for approximately 2-3 hours after the patient returned from therapy

The record showed no documentation of a verbal or written response to the patient until 05/05/11 which was not within the seven day time frame.

5. Record review of Patient #52's Complaint/Grievance was received by the facility on 04/08/11.
-The grievance alleged the following:
-a nurse was not caring in her responses to the patient or to the complainant
-the nurse responded "Great" after seeing the patient had been incontinent of urine
-the nurse left a shirt wet with urine on the patient
-the nurse put the wet clothes in the patient's chair

The record showed no documentation of a verbal or written response to the patient until an internal letter (a written communication from designated staff such as the nurse manager which is handed to the patient while in the hospital which addresses the complaint in an informal manner; the internal letter does not follow the steps required of the regulation) dated 05/10/11 was given to the complainant.

6. During an interview on 05/20/11 at 9:10 AM Staff B, Director of Quality/Risk Management, stated that the documentation of dates on the grievance log did not meet the regulation requirement for contacting the complainant in a timely manner because there was no written documentation of what was discussed and the grievances were not addressed in seven days as the policy directed.

Based on record review and interview the facility failed to provide the patient a written response which accurately informed them of the steps taken on behalf of the patient during investigation and the results of the investigation after a grievance was made for two (#50, #52) of six discharged patient records. This had the potential to affect all patients. The facility census was 92.

Findings included:

1. Record review of Patient #50's Complaint/Grievance was received by the facility on 04/25/11. The grievance alleged the following:
-call light was not answered when he/she had to go to the bathroom and the patient called his spouse at home and the spouse arrived (approximately 45 min) before anyone from the facility responded to the call light

The record showed no documentation of a verbal or written response to the patient until an internal letter dated 05/04/2011 was given to the patient which stated the following:
-a thank you for sharing the concerns regarding the slow response time to both the call bell and the patient's bladder scan needs
-an apology on behalf of the hospital for any discomfort the patient may have experienced
-a hope that the staff has met the patients needs to resolve the issue
-an extension number and name of a contact person for the facility if the issue was not resolved to the patients satisfaction or if the issue re-occurs.

The grievance log provided by the facility states the internal letter (a written communication from designated staff such as the nurse manager which is handed to the patient while in the hospital which addresses the complaint in an informal manner; the internal letter does not follow the steps required of the regulation) was given to the patient on 5/4 (no year given).



2. Record review of Patient #52's Complaint/Grievance was received by the facility on 04/08/11. The grievance alleged the following:
--a nurse was not caring in her responses to the patient or to the complainant
-the nurse responded "Great" after seeing the patient had been incontinent of urine
-the nurse left a shirt wet with urine on the patient
-the nurse put the wet clothes in the patient's chair

The record showed no documentation of a verbal or written response to the patient until an internal letter dated 05/10/11 was given to the complainant which stated the following:
-I am aware that you had concerns about the care and treatment of your brother in law.
-I hope that the staff has met your expectations and that (the patient) is receiving the care he/she needs.
-If the issue is not resolved to your satisfaction, or if it re-occurs, please let me know.
This was followed with a phone number and signature of facility staff.
The facility did not include in their response the information as required by the regulation.

3. During an interview on 05/20/11 at 9:15 AM Staff B, Director of Quality/Risk Management stated the internal letters were given to the patients while they were in the hospital and no other letter was sent by the facility.

Based upon observation and interview, the facility failed to protect the patients' privacy by
displaying patient names outside patient rooms and on the dry erase board in a Rehab (Rehabilitation) gym. This had the potential to affect all patients privacy except those who remained anonymous for safety. This applied to 91 of 92 patients on 2nd, 3rd and 4th floors. The facility census was 92.

Findings included:

1. Observations on 05/17/11 and at various times throughout the survey showed the patients' first name and last initial posted outside the room doors on the second, third floor for 37 of 38 patients, and fourth floors, which failed to protect the patients' personal privacy as a patient of the facility.

2. Observation on 05/20/11 at 10:30 AM, of the fourth floor Rehab gym showed patients' last name posted on a dry erase board. Patient names were visible to public in the general hallway.



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3. During an interview on 05/17/11 at 10:00 AM, Staff NN, second floor Nurse Manager, stated that it was his/her understanding that staff could post patients' first name and last initial outside of the patient rooms.


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Based on interview, record review and policy review the facility failed to ensure staff followed the Code Blue (the procedure followed when a patient is assessed to be in cardiac and/or respiratory arrest i.e. cessation of breathing and/or cardiac function) policy when a patient became unresponsive and pulseless for one (#15) of three mortality records reviewed. This would have the potential to affect all patients. The facility census was 92.

Findings included:

1. Review of the policy titled Code Blue dated 1/10 showed:
-Purpose of Policy: The purpose of this policy is to ensure an immediate and efficient response in the event of a cardiopulmonary arrest.
-Basic Life Support should be initiated and continued until EMS (Emergency Medical System) team arrives.

2. Review of discharged Patient #15's medical chart showed the patient was admitted to the facility on 11/15/10.

Record review of the Discharge Summary dictated 11/16/10 showed the patient was in the therapy gym and became unresponsive at approximately 3:00 PM on 11/16/10. The patient was then transported by wheelchair to his/her room at 3:04 PM which was approximately 175 - 200 feet from the gym. The Urgent Care Record dated 11/16/10 showed the resuscitation began at 3:10 PM and ended at 3:23 PM when death was pronounced by a physician.

During an interview on 05/19/11 at 3:25 PM, Staff B, Director of Quality/Risk Management, stated that the resuscitation efforts should have begun in the gym and the patient should not have been transported to his/her room to begin resuscitation.

During an interview on 05/19/11 at 4:15 PM, Staff EE, Physical Therapy Supervisor, stated that the physical therapy staff should have put the patient on the mat in the gym, checked for a pulse; and if pulseless; called a Code Blue; and started Cardiopulmonary Resuscitation (CPR).

Based on observation, interview, record review and policy review the facility failed to follow policy and procedure for medication administration and allowed OT (Occupational Therapy) staff to administer topical medications to one (#29) of three patients observed. The practice of OT administering medications does not allow for the nursing process to evaluate the patient's current condition, need for a change or increase/decrease in medication, or the patient's outcome from the medication administration. This had the potential to affect all patients receiving topical medications. The facility census was 92.

Findings included:

1. Record review of the facility's policy titled "Medication Administration", revised 12/2008 showed the following direction:
- POLICY: Registered Nurses [RN's] and Licensed Practical Nurses [LPN's] will administer prescribed medication in accordance with Missouri State Nurse's Practice Act and other state or federal regulations;
-SKILL LEVEL: RN's may administer . . . topical [medications]. LPN's may administer . . . topical [medications];
-PURPOSE OF POLICY: The purpose of this policy is to establish consistent guidelines to ensure that The Rehabilitation Institute of St. Louis promotes quality and safe patient care by maintaining a system for safe medication administration;
-PROCEDURES: Observe patient taking the medications.

2. Review of Patient #29's medical record showed the following physician's order dated 04/13/11 at 3:45 PM:
"Skin care recommendations; may use Interdry Ag sheets [Coloplast Interdry Ag is the brand name of a dressing made with a knitted polyester woven textile material that provides a soft, comfortable, non-friction surface. Reduction of friction is very important in of avoiding skin tears and pressure ulcers. A special proprietary polyurethane coating on the dressing allows for moisture translocation by wicking moisture within the fabric and efficiently evaporating moisture out of the skin fold] under breasts and or Nystatin Powder [an antifungal medicine used to treat certain kinds of fungal or yeast infections of the skin]. (Ny) [Nystatin Powder] Groin and pelvic area clean with Remedy Foam cleanser [ready-to-use, no rinse foam body cleanser that gently cleanses and conditions the skin without stripping it of its natural oils], calazime cream [zinc oxide-based barrier that protects against moisture and minor irritation. Menthol cools irritated skin and calms inflamed tissue. Calazime also absorbs light exudate from compromised skin] to bilateral groin areas & dust with Nystatin powder daily or prn as needed."

During an interview on 05/18/11 at 8:50 AM, Staff Z, RN, stated that OT staff would administer the Nystatin powder to Patient #29 when they help the patient with bathing and dressing.

During an interview on 05/18/11 at 9:30 AM, Staff H, RN, Nurse Manager stated that OT staff cannot administer medications to patients.

During an interview on 05/18/11 at 11:50 AM, Staff B, RN, Chief Nursing Officer, stated that OT staff cannot administer medications to patients as described with bathing/dressing activities or anything else ordered by a physician and unrelated to therapies.

During an interview on 05/19/11 at 3:00 PM, Staff BB, MD, Medical Director, stated that OT staff should not be administering prescribed medications to patients.

Observation on 05/20/11 at 12:00 PM during exit conference, Staff HH, Rehabilitation Director, stated that therapies were authorized to administer medications.


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Based on interview, record review, and policy review, the facility failed to follow policy and procedure during blood administration for three (#39, #44, and #46) out of three patient medical records reviewed for blood administration. This had the potential allow for any patients receiving blood to have negative outcomes related to the transfusion. The facility census was 92.

Findings included:

1. Record review of the facility's policy titled, "Blood and Blood Components Administration" dated 01/10, showed a blood transfusion will be administered upon a physician order and a physician order must be obtained for transfusion of any blood/blood products.

Review of discharged Patient #39's medical record showed that there was no physician's order written for two units of blood that were transfused to the patient on 05/03/11.

During an interview on 05/20/11 at 10:25 AM, Staff L, Third Floor Manager stated that a physician's order is required before blood can be transfused.

2. Review of the facility's Blood Administration form showed directions for the staff to record transfusion vital signs 15 minutes after the transfusion begins, then hourly until completed, and one hour after the transfusion is completed.

Review of discharged Patient #44's medical record showed that the Blood Administration form, dated 05/11/11, contained the patient's vital signs recorded at the following times, (which were not according to the directions on the form):
- 6:00 PM (before the transfusion began);
- 7:00 PM (when the transfusion began);
- 7:15 PM (15 minutes after the transfusion began);
- 9:00 PM (vital signs should have been recorded at 8:15 PM and again at 9:15 PM);
- 10:30 PM (vital signs should have been recorded at 10:15 PM and 11:15 PM);
On a separate section of the form titled "one hour post transfusion vital signs" staff documented vital signs at 8:00 PM and should have documented one hour after the conclusion of the transfusion at 11:30 PM. The facility's form titled, "Request for Blood Products" showed the blood transfusion was actually completed at 10:30 PM. This indicated that the patient should have had an additional set of vital signs recorded at 11:30 PM.

3. Review of discharged Patient #46's medical record showed that the Blood Administration form, dated 03/29/11, contained the patient's vital signs after a blood transfusion was completed, but did not indicate what time the vital signs were taken.

During an interview on 05/20/11 at 10:25 AM, Staff L stated that the vital signs for Patient #44 and #46 were not completed correctly by the nursing staff during the blood administration (after reviewing the medical records).

Based upon record review and interview, the nursing service failed to document patients' intake of supplements for two (Patients #17 and #18) of two patients reviewed in a total of 18 patients receiving supplemental foods and snacks so that accurate assessment could be made of their nutritional intake. The facility census was 92.

Finding included:

1. Review of the facility policy, "Supplemental, Enteral (feeding directly into the stomach using a tube)and TPN (total parenteral nutrition, complete feeding by intravenous feedings)", dated 12/08, showed that supplemental consumption is to be documented on intake section of nursing flow sheet.

2. Medical record review of Patient #17, a 19 year old admitted since 03/07/11 for rehabilitation for injuries sustained in a motor vehicle accident, showed the patient was to receive Ensure Plus (a supplement of high protein, high calorie value, served as a drink) three times per day. Review of the documentation to indicate the patient's consumption of the supplement showed that the documentation was absent, a failure to follow the facility's policy.

3. Medical record review of Patient #18, a 27 year old with a craniectomy as a result of a recent brain aneurysm, showed the patient was to receive Ensure (a high protein drink) three times per day. Review of the documentation for the amount consumed by the patient showed that the documentation was not done. This is important so that the Registered Licensed Dietitian can make an accurate assessment of the patient's nutritional status regarding the full intake of food values, including the supplements.

4. During an interview on 05/17/11 at 9:15 AM, Staff I, the Registered Licensed Dietitian (RDLD) stated that the documentation is usually not completed.

Based upon record review, interview and review of facility policy, the physician(s) failed to have completed documentation for Discharge Summaries for six (Patients #21, #22, #23, #24, #25, #14) of six patient records reviewed for discharge summaries, in order to inform the health care team during the next episode of a patient's care. The facility census was 92.

Finding included:

1. Review of undated Medical Staff Bylaws showed a section of four points to begin with the statement, "A discharge summary (clinical resume) shall be written or dictated on all medical records promptly, but no later than within thirty (30) days of discharge."

2. Review of the facility policy, "Analysis of Content of Medical Records", dated 04/09, showed: Discharge Summary/Attending Physician - The discharge summary is dictated by a resident physician. Attending physician must sign it within thirty (30) days after discharge.

3. Medical record review for Patient #21, admitted 03/28-04/12/11 for rehabilitation after a leg amputation, showed the discharge summary to have been written, signed and dated on 05/17/11. This date is more than 30 days past the day of discharge.

4. Medical record review for Patient #22, admitted 03/25-04/12/11, showed the discharge summary to have been dictated on 04/12/11 and transcribed on 04/25/11. The document was signed by the physician, but lacked the date and time of signing. It is not possible to determine if the documentation was signed in a timely manner or not.

5. Medical record review for Patient #23, admitted 04/07-12/11, showed the discharge summary to have been dictated, signed, dated, and timed on 05/17/11. This date is more than 30 days past the day of discharge.

6. Medical record review for Patient #24, admitted 03/31-04/12/11, showed the discharge summary to have been dictated on 04/12/11 and transcribed on 05/16/11. The document was signed on 05/19/11, which is more than 30 days past the day of the patient's discharge.

7. Medical record review on 05/18/11 at 2:30 PM, for Patient #25, admitted 03/21-04/12/11, showed the medical record to lack a discharge summary. The record review date was beyond the 30 day requirement for the discharge summary completion.

During an interview on 05/17/10 at 10:30 AM, the Staff U, the Director of Medical Records, stated that when the Discharge Summaries are due, he/she will find the physician and get the reports completed. Staff U also stated that the quality monitoring was acceptable at 28% delinquent for the first quarter of 2011.



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8. Record review of discharged Patient #14's medical record showed the patient was admitted to the facility on 02/16/11 for seizures and functional decline and expired on 02/25/11.
Record review of the Discharge Summary showed:
-the summary was dictated on 04/19/11 and transcribed on 04/20/11.
-the summary was signed, dated and timed by the Resident Physician on 04/21/11 at 1:35 PM and the Attending Physician on 04/22/11 at 3:00 PM.

The summary was authenticated more than 30 days past the day of discharge.

Based on observation, interview, record review, and policy review the facility failed to:
- Have processes in place to reconcile and monitor medications (the process of comparing a patient's medication orders [those newly prescribed] with all the medications the
patient takes [previously prescribed] as well as self-prescribed, including
over-the-counter products such as herbals and supplements, this process must be continually checked across the continuum of care. The goal of medication reconciliation is to prevent adverse drug events that could occur by allergic reactions, omissions, substitutions,
and/or duplications);
- Follow their policies and procedures regarding the storage and reconciliation of medications brought into the facility by patients;
- Ensure controlled substances were counted, stored, and reconciled according to policy;
These failures had the potential to affect all patients admitted to the facility. The facility census was 92.

The severity and cumulative effect of this systemic practice resulted in non-compliance with 42 CFR 482.25 Condition of Participation: Pharmaceutical Services.

Refer to evidence A-0491 and A-502 for findings.

Based on observation, interview, record review, and policy review the facility failed to have a system in place that ensured the security of controlled (drugs whose general availability is restricted; any one of a number of drugs or other substances which are strictly regulated or outlawed because of their potential for addiction and abuse) medications and uncontrolled medications in a safe and professional manner. The facility allowed nurses to be in control of large numbers of narcotics without any check, count, documentation, supervision, or method of accountability. This had the potential to affect all patients in the facility. The facility census was 92.

Findings included:

1. Record review of the facility policy titled, "Medications Brought From Home", dated 03/11, gave the following direction to staff:
POLICY: Patient's own medications shall not be used unless there is a physician's order stating that the patient may take his/her own medications.
PROCEDURES: Medications brought from home that will not be used:
- All medications are given back to the patient's family to be taken home;
- If the patient's family cannot be notified, then all medications are placed in a bag. A list of the medications (plus a carbon copy) is placed into the bag, the patient's name and room number and the date are noted;
- The medications are then placed in the designated safe and the carbon copy is initialed as received and sent back to the floor as a receipt for the patient. The nurse supervisor on duty should be paged to open the safe so medications can be placed inside. Only the nurse supervisors know the combination to the safes;
- When the patient is discharged, the receipt will be checked against the meds [medications], and the medication will be turned over to him/her. No medication will be returned without a receipt;
Once a patient has been discharged and his/her medications have not been picked up within 30 days, this medication will be discarded in a manner that is safe and in accordance with DE [Drug Enforcement Administration] requirements, where applicable.

Record review of the facility policy titled, "Medications Brought From Home", dated 05/11 and revised 05/17/11 (during survey), showed the following changes to the facility policy:
- Medications will be placed in the designated safe in the house supervisor's office and the carbon copy is initialed as received and sent back to the floor as a receipt for the patient. The nurse supervisor on duty should be paged to open the safe so medications can be placed inside. Only the nurse supervisors know the combination to the safe;
- [added to policy] The contents of the safe will be reviewed on a weekly basis and noted by the initial/date of the supervisor on the safe log in order to ensure the procedure for discarding medications will be met timely.

Record review of the facility policy titled, "Medication Diversion Prevention" dated 04/11 showed that when patient home medications are brought in from home, a record of the number of pills received, administered, and wasted should be kept with the medications. Additionally, the policy showed that if a patient's medications are kept in a locked cabinet, the record should reflect a count of the controlled substances (drugs which are regulated due to their potential for abuse or addiction) at the end of each shift.

Record review of the facility policy titled, "Medication Diversion prevention" dated 04/11 showed that two nurses, one from the departing shift and one from the on-coming shift, will conduct a count of controlled medications during the shift [meaning the facility will count the number of pills available to the patient and compare against the number of pills the patient was administered to ensure there are no discrepancies]. The policy also showed that the supervisor is responsible for assigning a person responsible for the end of shift count (a count completed by staff every 12 hours of the controlled medications stored outside of the pharmacy).

2. Observation on 05/17/11 at 9:50 AM in the fourth floor medication room showed Staff H, RN (Registered Nurse), Nurse Manager, opened the drawer labeled Patient Home Meds and stated that the drawer lock had been broken for some time. The contents of the drawer were for two patients (#26 and #27). The medication for Patient #26 was Temazepam (a medication used for short term treatment of sleeplessness or the ability to stay asleep). The medication had not been secured due to the broken lock and was available to anyone accessing the medication room. The facility failed to follow the facility policies and procedures as described in "Medications Brought From Home", dated 03/11 and "Medication Diversion prevention" dated 04/11.

3. Observation on 05/17/11 at 9:55 AM in the fourth floor medication room, showed a combination locked safe, partially covered, located on a bottom shelf behind closed cabinet doors. Observation of the contents of the safe showed a plastic bag of medications belonging to Patient #28 who had been admitted 01/26/11 and discharged on 02/03/11. Contents of the plastic bag revealed 13 bubble-packed cards containing 456 pills of Hydrocodone, (or dihydrocodeinone is a semi-synthetic opioid [naturally occurring opium-containing substance] considered as a class II [narcotic] medication and a controlled substance). Staff H, RN, stated the combination to the safe was only known to he/her and the house supervisor. The facility failed to follow the facility policies and procedures as described in "Medications Brought From Home", dated 03/11 and "Medication Diversion prevention" dated 04/11.

During an interview on 05/17/11 at 9:55 AM, Staff H, RN, stated that the safe was empty and, "we don't use it". After the safe was opened, Staff H stated that he/she didn't know how the medications got in the safe and only he/she and the house supervisors had the combination to open the safe.

4. During an interview on 05/17/11 at 10:30 AM, Staff J, R.Ph., Director of Pharmacy, stated he/she was not aware that there were safes in the medication rooms and was not aware that medications brought in with patients were stored in the safes. Staff J stated he was responsible for all policies and procedures related to medication storage in the facility.

5. During an interview on 05/18/11 at 9:30 AM, Staff H, RN, Nurse Manager stated that on 05/17/11, he/she had called Staff MM, RN, nurse who admitted the patient, and discussed the medications found in the safe. Staff H stated that Staff MM reported that he/she gave Staff H the medications and watched as they were locked in the safe. Staff H stated he/she does not remember doing that.

6. During an interview on 05/18/11 at 1:00 PM, Staff MM, RN, stated that he/she gave the medications to Staff H, RN, Nurse Manager, and watched as he/she put the medications in the safe in the medication room. Staff MM stated there was no process to secure or list patients' belongings. Patient #28's items were not listed or documented in the patient's medical record per policy.


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7. Record review of the third floor's form titled, "Pyxis (electronic medication dispensary) Controlled Substance Inventory Record" showed that the facility failed to complete the controlled substance count (a count of medications stored outside of the pharmacy that are high risk for theft and non-prescribed use), per policy, for 157 out of 186 shifts between 02/13/11 and 05/15/11. This prevented accurate monitoring of the controlled substances between shifts, potentially allowing for easy misuse of the medications.

Based on observation, interview, and policy review, the facility failed to ensure medications stored outside of the pharmacy were secured from unauthorized access by using a locking mechanism on the facility's emergency carts that broke easily, and by storing the emergency carts containing the medications in a secluded area, not visible from the nurse's station. This had the potential to allow unauthorized access to medications stored in the emergency carts located on the third floor. The facility census was 92.

Findings included:

Record review of the facility's policy titled, "Medication Storage" revised 03/11, showed that all medications will be stored in a locked medication cart, Pyxis (electronic medication dispensary), and/or locked storage.

1. Observation on 05/19/11 at 8:50 AM of the third floor, showed an emergency cart located in a secluded hall, not visible from the nursing station. The emergency cart locking device was an integrity seal (a thin, plastic, numbered tag) which broke when turned to view the lock number, allowing unauthorized access to the contents located inside the emergency cart. Inspection of the inside of the cart showed a plastic container with a lid containing the following medications:
- Two 81 milligram (mg) Aspirins (prevents blood clots);
- Two 2.5 mg Albuterol (treatment for asthma) unit doses;
- One GlucaGen (increases an extremely low blood sugar) injectable;
- One 25 gram Dextrose 50% (increases an extremely low blood sugar) injectable;
- Two 30 milliliters (ml) Maalox (reduces stomach acid) liquids.
During this observation, along with Staff L, Third Floor Manager, the emergency cart was secured with another integrity seal, which broke easily with a gentle turn.

During an interview on 05/19/11 at 9:00 AM, Staff L stated that the facility realized the integrity seals break too easily, leaving the contents of the cart unsecured. Staff L added that the third floor emergency cart was found with the lock broken on 05/18/11, but was not sure how it was broken, or how long it had been broken.

Based on interview, record review, and policy review the Registered Licensed Dietitians failed to monitor nutritional status for two (#18 and #6) of eight patients reviewed for complex nutritional needs. Failure to monitor nutritional status potentially leads to slower healing time and increased risk of complications. The facility census was 92.

Finding included:

1. Record review of the facility policy titled, "Nutritional Screening and Assessment", dated 05/09, showed the expectation that patients with a low nutritional risk may have follow-up monitoring "PRN (as needed) as determined by the Dietitian or per physician consult."

2. Review of current Patient #18's medical record showed a 27 year old admitted on 04/15/11. The Registered Licensed Dietitian (RDLD) provided a nutritional assessment on 04/16/11, with follow-up on 04/20/11 and 04/27/11. No further nutritional monitoring had been documented for Patient #18 to assess safety and effectiveness of the supplement. This patient was receiving the high protein, high calorie nutritional supplement three times per day to help prevent weight loss. The notes show a loss in weight from 04/27/11 at 123.2 pounds to 118 pounds on 05/04/11. There was no documentation for the intake of the supplement. The RDLD is unable to assess both weight variances and renal tolerance for high protein intake, without full documentation of what the patient actually consumed.

3. During an interview on 05/17/11 at 9:00 AM, Staff F, Lead Dietitian, stated that when a patient is determined to be suitable for PRN follow-up, the RDLD might not document again during the current admission.



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4. Review of current Patient #6's medical record showed a 54 year old admitted on 05/02/11 for multiple (14) fractures. Staff F, RDLD, provided a nutritional assessment on 05/04/11 and documented this patient to be a low nutritional risk. Patient #6 had low Albumin (a simple protein that is used as a tool in determining nutritional status) laboratory values on 05/03/11 of 3.5, 05/05/11 of 3.5 and 05/06/11 of 3.4 (normal range is 3.5-5.5 g/dl with optimal range 4.5-5.0 g/100ml), however there was no documentation in the patient's medical record to reflect a follow up evaluation for nutritional status. The Patient's Interdisciplinary Plan of Care in the medical chart on 05/17/11 was completely blank for nutrition/hydration. Martin Yahiro, M.D. and consultant to the FDA (Food and Drug Administration) stated, "One of the most important influences on fracture healing is nutrition. The healing time for broken bones is influenced by a number of variables that are impacted by the availability of key nutrients to support bone healing and a healthy blood supply."

During an interview on 05/17/11 at 12:40 PM, Staff F, RDLD, stated that he/she would not change the assessment of Patient #6 but was not aware that the Albumin laboratory values had been low to below normal.

Based on observation, interview, and email review, the facility failed to ensure unusable supplies were removed from patient care areas by failing to discard undated or outdated supplies. This could allow expired supplies to be used on patient's or on patient testing devices. This had the potential to affect all patients in the facility. The facility census was 92.

Findings included:

1. Observation on 05/17/11 at 9:40 AM showed a bottle of opened sterile water and a bottle of Cara Klenz (wound cleanser) on the counter of the room of Patient #1. Their was no date written on the bottles to show when they had been opened for use.

-During an interview on 05/17/11 at 9:42 AM Staff MM, second floor nurse manager, stated that the bottles should be dated when they were opened.

2. Observation on 05/17/11 at 9:58 AM showed a bottle of opened sterile water and Hydrogen Peroxide on the bedside table of the room of Patient #2 with no date written on the bottles to show when they had been opened for use.

3. Observation on 05/17/11 at 10:10 AM showed two bottles of opened sterile water and one bottle of opened Hydrogen Peroxide on the counter of the room of Patient #3 with no date written on the bottles to show when they had been opened for use.




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4. Observation on 05/17/11 at 10:05 AM of a third floor glucometer (tests blood sugar), showed a "high" glucose controller liquid (used to test if sugar monitoring devices are working correctly) was open and without an open date written on the bottle. The control also showed an expiration date of 04/11, which was verified by Staff L, Nurse Manager.

5. Observation on 05/17/11 at 1:00 PM of the third floor medication room, showed the following expired supplies:
- Three Rate Flow Regulators (controls fluid or medication administration rate), Lot #080918L, expired 04/11;
- One Rate Flow Regulator, Lot #50619L, expired 04/08;
- Five Secondary IV (Intravenous - in the vein) set (used to infuse IV medications or fluids), Lot #0060850730, expired 04/11;
- Filter Straw (prevents glass from entering medications when mixing them), Lot #60264041, expired 10/06.

During an interview on 05/17/11 at 1:00 PM, Staff L verified that the supplies were expired and said that it was the responsibility of the Central Supply staff to remove the expired supplies.

Record review of an email dated 05/27/11 at 2:47 PM from Staff C, Director of Quality and Risk, showed that the facility did not have a policy for the management of expired supplies.

Based on interview and policy review the facility failed to provide accurate direction in their infection control policies and procedures to prevent infectious/communicable diseases in the acute care setting. Policies and procedures directed staff to use an alcohol-based hand rub product (e.g., liquid, gel, or foam hand sanitizers) for hand hygiene purposes when caring for a patient with Clostridium difficile or C. diff (a spore forming bacterium that causes severe diarrhea and other intestinal disease). Guidelines for Hand Hygiene in Healthcare Settings Published 2002, dated October 25, 2002 / Vol. 51 / No. RR-16 state that soap and water is the recommended method of hand hygiene when caring for patients with C-diff.

The facility's infection control policies and procedures failed to instruct staff to use contact isolation precautions for types of bacteria resistant to many antibiotics:
- C. diff;
- Methicillin-resistant Staphylococcus Aureus (MRSA);
- Vancomycin-resistant Enterococci (VRE).
Patients with these Multidrug-resistant organisms (MDRO's) received rehabilitation services in the common gym areas with uninfected patients (often side by side on mattresses) and the rehabilitation equipment was cleaned only once per day while the Management of
Multidrug-Resistant Organisms In Healthcare Settings, 2006 Guidelines specify routine (a prescribed, detailed course of action to be followed regularly; a standard procedure) cleaning of the equipment and environment. The facility's failure to direct staff with policies and procedures based on accepted guidelines puts all patients at risk. The facility census was 92.

Findings included:

1. The Centers for Disease Control and Prevention (CDC) Guidelines dated 10/25/2002, state that C. diff spores are transferred patient to patient mainly via the hands of healthcare personnel who have touched a contaminated surface or item and staff should not use an alcohol-based hand rub product in place of soap and water handwashing.

2. Record review of the facility's policy titled, "Hand Hygiene", last dated 08/08, showed the following:
- POLICY: Each employee will wash his or her hands appropriately while within the facility.
- PROCEDURES: After caring for an infected/colonized (colonization occurs when a patient has an organism in or on them but has not become ill with the disease) patient who harbors organisms of special significance, re: MRSA, VRE, or other multiple-resistant organisms.
Hand hygiene with the waterless solution should be performed upon entering and leaving a room; whenever hands are not visibly soiled; or if running water and soap is not available.

The Guidelines for Hand Hygiene in Healthcare Settings Published 2002, dated October 25, 2002 / Vol. 51 / No. RR-16 state that soap and water is the recommended method of hand hygiene when caring for patients with C-diff.

3. Record review of the facility's policy titled, "Cleaning of Equipment" dated 10/08, showed direction for the facility staff to clean soiled equipment after every patient before it can be used by or for another patient and to wipe down therapy equipment with approved disinfectant at the end of every working day.
References for the Hand Hygiene Policy showed: CDC Guidelines for Hand/Hospital Environmental Control, 1988; and CDC Hand Hygiene Guidelines, 2002.

The Management of Multidrug-Resistant Organisms (MDROs) In Healthcare Settings, 2006 Guidelines specify routine (a prescribed, detailed course of action to be followed regularly; a standard procedure) cleaning of the equipment and environment.

4. Record review of the facility's undated algorithm (step-by-step problem solving procedure) titled, "Care of the Patient with MRSA or VRE", showed the following direction to staff:
- Evaluate patient's ability to control secretions (dressings, briefs, catheter, etc);
- [If the answer is yes] Handwashing: including Gel in Gel out [a term used to access an alcohol-based cleanser upon entering and exiting a patient's room] as stated in policy;
- Contain secretions with dressing, brief, or if in respiratory tract (patient can cough into tissue or trach [tracheotomy - surgically created airway opening in the neck] secretions contained).
- Therapy: Patient may go to therapy without any gown, gloves or mask. Patient has freedom to go anywhere within facility as long as secretions is contained.

5. Record review of the facility's policy titled, "TRISL" [The Rehabilitation Institute of St. Louis] Cdifficile Patient Care Instructions, dated 2/2010, showed the following direction to staff:
- Patient with suspected Cdifficile [C. diff] will be placed on Contact Precautions in private/blocked room per available bed;
- Hospital staff will always practice Contact Precautions (gown & gloves) upon entering the patient's room until isolation discontinued;
- Patient will remain on Contact Precautions until they have received 7 days of treatment and are no longer having diarrhea stools;
- When excretion is controlled or contained patient may go to gym for therapy. Patient should be in clean clothes. Gown & gloves are not required when leaving room;
- Patient [not staff] will complete hand hygiene with soap & water or alcohol foam before leaving room for therapy & upon returning to room from therapy . . .;
- Make sure all doctors, nurses, therapists and other hospital staff wash or foam their hands before they touch you or your surroundings.

6. Record review of the CDC - 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, showed the following infection control precautions to prevent transmission:
- MDRO's, use of contact precautions (CP) in acute care settings: Implement CP for all patients known to be colonized/infected with target MDROs;
- No recommendation can be made regarding when to discontinue CP;
- Use of Contact Precautions: Implement CP routinely for all patients colonized or infected with a target MDROs (MRSA, VRE, C. diff);
- Environmental Measures: Follow recommended cleaning, disinfection and sterilization guidelines for maintaining patient care areas and equipment. Prioritize room cleaning of patients on Contact Precautions. Focus on cleaning and disinfecting frequently touched surfaces (e.g., bed rails, bedside commodes, bathroom fixtures in patient room, doorknobs and equipment in immediate vicinity of patient;
- Don gowns and gloves before or upon entry to the patient's room or cubicle;
- When active surveillance cultures are obtained as part of an intensified MDRO control program, implement CP until the surveillance culture is reported negative for the target MDRO.

7. During an interview on 05/18/11 at 1:30 PM, Staff AA, RN (Registered Nurse), Infection Control Nurse, stated that he/she was following the CDC Guidelines. Staff AA also stated that it was in the guidelines to use alcohol based hand rub when caring for a patient with C. diff. Staff AA said that all patients go to the gym and only some patients with C. diff are put on contact isolation and no patients with MRSA or VRE are put on contact isolation.

8. Observations throughout the survey of the outpatient therapy gym, second floor therapy gym, and fourth floor therapy gym showed patients using and sharing multiple pieces of equipment in the gyms, without in-between cleanings.

9. During an interview on 05/18/11 at 1:30 PM, Staff AA, Infection Control/Wound Care Coordinator, stated that the facility used a chlorine based spray to clean therapy gym equipment that may have been contaminated with C. diff, because bleach is the only product that kills C. diff and its spores. Staff AA added that he/she was not sure if the staff were using the chlorine based spray for cleanings.

10. Record review of the facility's Material Safety Data Sheet for Neutral Quaternary (Quat) Disinfectant Cleaner (spray cleaner found for use in the therapy gyms on the third and fourth floors) and Sani-Cloth wipes (disinfectant wipes found in the therapy gyms on the first, third, and fourth floors) did not contain sodium hypochlorite (bleach). CDC guidelines showed solutions without bleach were not effective in killing C. diff spores.

11. During an interview on 05/19/11 at 11:20 AM, Staff II, Occupational Therapist, stated that the therapy gym mats and equipment were cleaned with Sani-Cloths or Neutra Quat Spray, and indicated that they were the same and effective for all cleaning.

12. During an interview on 05/19/11 at 10:00 AM, Staff Q, Director of Therapy Operations, stated that he/she doesn't know what therapy staff used to clean the equipment and doesn't know what is in the cleaning solution.

13. During an interview on 05/19/11 at 11:40 AM, Staff JJ, Physical Therapist stated that the therapy gym mats were cleaned at the end of the day and several times throughout the day. Staff JJ stated that at the end of the day the mats were cleaned with Neutra Quat.

14. During an interview on 05/19/11 at 3:00 PM, Staff BB, M.D., Chief Medical Officer, stated that using an alcohol based hand gel product was not an acceptable practice when caring for patients with C. diff. Staff BB stated that he/she was unaware that the rehabilitation equipment in the gyms was only cleaned once per day. Staff BB also stated that the facility had been using standards for long term care facilities and would have to improve their practices to comply with acute care standards.


29047

Based on observation, interview, record review, and policy review, staff failed to follow their policy for hand hygiene for four (#45, #40, #41, #42) of 16 patients observed during patient care and failed to maintain equipment in a safe and sanitary manner. These practices have the potential to put all patients at risk for infection. The facility census was 92.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene", dated 08/08, showed the following direction:
- Wash their hands appropriately while within the facility;
- Wash their hands after removing gloves;
- Wash their hands before and after patient contact;
- Perform hand hygiene with a waterless solution [alcohol-based hand rub] upon entering and leaving a room.

Record review of the Centers for Disease Control 2007 (most recent) guidelines for "Preventing Transmission of Infectious Agents in Healthcare Settings" showed that alcohol does not kill C. diff spores (a spore forming bacterium that causes severe diarrhea and other intestinal disease) and that the use of soap and water is more efficacious (effective) than alcohol-based hand rubs.

Record review of the facility's "Infection Control Plan 2011 & Analysis of 2010 Data" showed that the hand washing compliance rate for 2010 was 66%.

The Journal of Hospital Infection dated, 2010 Nov;76(3):252-5. Epub 2010 Sep 20, stated, "this observational study measured healthcare workers' (HCWs'), patients' and visitors' hand hygiene compliance over a 24h period in two hospital wards using the 'five moments of hand hygiene' observation tool. Hand hygiene is considered to be the most effective measure in reducing healthcare-associated infections but studies have reported suboptimal levels of compliance. Most studies have used random observational time-periods for data collection and this has been criticized. We monitored a total of 823 hand hygiene opportunities (HCWs, N=659; patients and visitors, N=164). Among HCWs [health care workers], compliance was, 75% for nurses, 78% for allied health professionals."

2. Observation on 05/17/11 at 9:45 AM showed Staff X, RN (Registered Nurse) entered Patient #45's room to do a dressing change. Staff X donned gloves and removed the soiled dressing. Using the same contaminated gloves, Staff X cleaned the incision with saline and gauze pads and opened a sterile bandage package. Staff H, RN, Nurse Manager, walked across the room and got three pairs of clean gloves and put them down in front of Staff X on the patient's bed. Staff X removed the gloves, did not perform hand hygiene, and donned another pair of gloves. Staff X picked up the sterile bandage that had already been contaminated and put the bandage on the patient's incision. Staff X removed the gloves, did not perform hand hygiene, and pressed the bandage firmly on the patient's skin to secure the adhesive. Staff X, with ungloved hands, collected all of the dirty dressing still laying on the bed and put it in the trash before using alcohol based hand gel.

3. During an interview on 05/17/11 at 10:00 AM, Staff H, RN, Nurse Manager, stated that Staff X, RN, failed to perform hand hygiene between glove changes.

4. During an interview on 05/18/11 at 11:50 AM, Staff B, RN, Chief Nursing Officer, stated that he/she was aware that Staff X had not performed hand hygiene during the dressing change on 05/17/11 and stated that hand hygiene should be performed before donning and after doffing gloves.

5. Observation on 05/17/11 at 10:45 AM in the third floor therapy gym showed Staff O, Physician, examined (touching the patient, assessing the patients strength, and looking at the patients skin) Patient #40. Staff O then examined Patient #41, without performing hand hygiene between patients. Staff O examined a third patient, Patient #42, and again failed to perform hand hygiene between patients. The observation was verified by Staff L, third floor nurse manager.

During an interview on 05/19/11 at 1:30 PM, Staff B, CNO (Chief Nursing Officer), stated that he/she believed the facility has many opportunities to improve infection control and that hand washing should occur before and after touching a patient or their environment.

6. During an interview on 05/18/11 at 1:30 PM, Staff AA, Infection Control/Wound Care Coordinator, stated that staff can use alcohol based hand sanitizers while caring for patients with C. diff. Staff AA stated that alcohol based hand sanitizers were recommended for use in the prevention of transmission of C. diff based on the Centers for Disease Control (CDC) Guidelines update from 2008.

During an interview on 05/19/11 at 1:30 PM, Staff B stated that hand hygiene for patients with C. diff should be with soap and water.

7. Record review of the facility's policy titled, "Cleaning of Equipment" dated 10/08, showed direction for the facility staff to clean soiled equipment after every patient before it can be used by or for another patient and to wipe down therapy equipment with approved disinfectant at the end of every working day.

Observations throughout the survey of the first, third, and fourth floor therapy gyms showed multiple patients using and sharing various pieces of equipment without in-between cleanings. This allowed for potential cross-contamination of microorganisms (tiny one-celled organisms, viruses, fungi, and bacteria) between patients.

8. Record review of the facility's "C difficile Patient Care Instructions" showed that when excretion (stool, wound drainage) is controlled or contained, the patient may go to the gym for therapy and that a gown and gloves are not required when leaving the room.

Record review of the Centers for Disease Control and Prevention 2007 guidelines for "Preventing Transmission of Infectious Agents in Healthcare Settings" showed that patients who are infected with C. diff should remain on contact precautions (private room, using gloves and gowns when coming in contact with the patient) for the duration of the illness.

During an interview on 05/18/11 at 1:30 PM, Staff AA, Infection Control Nurse, stated that in 2006, the facility's Infection Control practices were changed by an Infection Control Consultant. The changes allowed patients diagnosed with C. diff to come out of their rooms without contact precautions and participate in therapies provided in the therapy gym, as long as stool could be controlled by the patient or contained in a brief (adult diaper). Staff AA stated that when patients used the therapy gym and equipment, the gym and equipment were not cleaned after each patient use unless the equipment became soiled. Staff AA added that the gym and equipment were to be cleaned at the end of the day with a specific bleach containing spray because bleach is the only product that kills C. diff and its spores. Staff AA could not verify if staff were using the bleach containing spray for cleaning the gym and equipment.

Record review of the facility's Material Safety Data Sheet for Neutra Quat (Quaternary) Disinfectant Cleaner (spray cleaner found for use in the therapy gyms on the third and fourth floors) and Sani-Cloth wipes (disinfectant wipes found in the therapy gyms on the first, third, and fourth floors) did not contain sodium hypochlorite (bleach). CDC guidelines showed solutions without bleach were not effective in killing C. diff spores.

During an interview on 05/19/11 at 11:20 AM, Staff II, Occupational Therapist, stated that the therapy gym mats and equipment were cleaned with Sani-Cloths or Neutra Quat Spray, and indicated that they were the same and effective for all cleaning.

During an interview on 05/19/11 at 11:40 AM, Staff JJ, Physical Therapist, stated that the therapy gym mats were cleaned at the end of the day and several times throughout the day. Staff JJ stated that at the end of the day, the mats were cleaned with Neutra Quat.


29047

Based on interview, record review and policy review the facility failed to notify in a timely manner the Hospital Organ Procurement Agency of the deaths of patients in two (#14, #16) of three patients. This had the potential to affect all patients. The census was 92.

Findings included:

1. Review of the facility policy titled Organ/Tissue Donation Policy dated 06/09 stated:
- all deaths must be reported to the Hospital Organ Procurement Agency - Mid-America Transplant Services within one hour regardless of donation status.

2, Record review of Patient #14's medical chart showed the patient was admitted to the facility on 02/16/11 for seizures, functional decline and advanced Parkinson's disease.
The patient expired on 02/25/11.

Record review showed no documentation of notification to the Hospital Organ Procurement Agency.

3. Record review of Patient # 16 medical chart showed the patient was admitted to the facility on 08/24/10 for decreased functional status after a stroke.

Review of the Mortality Referral Form for MTS Phone Request of Anatomical Gifts Program states the patient was not a candidate for organ donation. but no documentation was found in the medical record related to the time the Hospital Organ Procurement Agency was notified of the time of death.

4. During an interview on 05/19/11 at 3:15 PM Staff C, Director of Quality/Risk Management stated that the Hospital Organ Procurement Agency were not notified in a timely manner by the facility staff.

Based on interview and record review the facility failed to ensure that interpretations of radiology reports are placed in the medical record of patients who receive radiological examinations. The census was 92.

Findings included:

1. Review of the document titled "Ancillary Services Agreement" showed that services to be provided under contract to the facility included radiology.

2. Record review of a policy titled "Outside Testing Procedures and Appointments" and dated January of 2010 showed that a radiology daily billing slip, patient referral form and radiology requisition will be completed for each radiology procedure. A portion of the radiology daily billing slip will be placed in the lab section on the medical chart. Information regarding the appointment is placed in the patient's medical record under consults.

3. Review of a document from the medical staff rules and regulations as approved by the governing body on 02/21/11 showed that the medical record shall include, where applicable, reports such as X-ray (radiology). Under another section it was stated that the contracted radiology service shall provide authenticated reports for all radiological examinations performed for the hospital and when requested for review of examinations performed outside the hospital. In either case this will provide the official report for the medical record.

4. During an interview on 05/18/11 at 9:40 AM Staff C (quality assurance coordinator) stated that the facility had not been able to ensure that radiology reports (interpretation or record of findings from a radiological examination) had been made part of the medical record. During a subsequent interview on 05/20/11 at 10:55 AM Staff C stated that previous attempts to secure the interpretations did not result in submission of the reports. Staff C provided the number of interpretations found to be present in the medical record. For January there were 20 tests performed with four medical records reviewed and no interpretations were included as part of the medical records. For the month of February there were 38 tests performed with three records reviewed and zero reports were found to be in the medical record.
This was the only data available for the months of January through April 2011 and showed that zero reports (interpretations) from radiological visits were included as part of the patients' records who received these examinations.

5. During an interview on 05/20/11 at 8:50 AM with Staff U (medical records director) stated that there is a review process for the placement of radiological reports in the medical record. Staff U stated that he/she had just recently received the interpretations (reports) for the months of January through April, 2011. He/she had not yet compared them to the medical record to determine which reports had or had not been included as part of the medical record.

6. During an interview on 05/20/11 at 8:50 AM Staff PP (controller) stated that there will be a new system to ensure that contracted services (including radiology) are being provided as necessary. The facility had only recently obtained 100% of the interpretations (record of findings from a radiological examination) completed for the months of January through April of 2011.