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Based on record review and interview, the facility failed to evaluate the quality of its contracted hemodialysis service.

Findings include:

Review of the Quality Committee Minutes revealed no data being reported by the contracted dialysis service.

During an interview on 3/21/12 at 11:32am in the conference room, staff #4 confirmed that the dialysis service was not providing data to the Quality Committee.

Based on observation and interview the hospital nursing staff failed to provide oral nutritional supplements and supplemental percutanious endoscopic gastric tube (PEG) feedings in a safe setting.

On March 20 2012 at 11:00 AM during the initial tour of the long term acute care hospital the refrigerator on the 6th floor, that was being used to house oral supplements was observed to have a temperature log taped to the outside door. The temperature log recorded daily temperatures. Twenty(20) temperatures for march (1-20)were recorded outside the recommended safe range for food storage. Day 1-8 were recorded as 32 degrees, days 9-15 were recorded as 33 degrees, 16-17 were 32 degrees and 18-19-20 were recorded as 33 degrees. Recommended temperature range is 36 to 38 degrees. No action was noted on the form to correct the refrigeration range to bring it into acceptable safe food storage parameters.

Upon opening the refrigerator the following items were found to be expired:
- 4 once (oz) Cranberry juice #7 expired 3/16/2012
- 4 oz Grape juice #9 expired 3/6/2012
- 4 oz Orange Juice #6 expired 3/6/2012
- 4 oz Apple juice #2 expired 3/16/2012

The refrigerator also contained a 32 oz fast food drink container with liquid in it, 3 brown sacks with patient snack items that were past the date of use. The refrigerator also was visibly soiled with juice rings from spilt juice in the door and on the shelves.

On March 20 2012 at 1:00 PM the Director of Nurses was shown the refrigeration log and confirmed all days from March 1 through March 20 were recorded on the log sheet as outside the recommended range for acceptable food storage. The expired content of the refrigerator and the spilled juice was also shown to the Director of Nurses who confirmed the items were as described above. She offered no explanation.

On the same day the refrigerator on the 5th floor was observed for temperature log and expired content. The refrigerator had not content but had three (3) thermometers .
- a round thermometer recorded the temperature as 40 degrees
- a flat thermometer recorded the temperature at 32 degrees
- a thermometer that hung from the steel shelf recorded 52 degrees.

A respirator technician, who was working in the area, was asked to visualize the three thermometers and confirmed they each had a different temperature. There was no recorded temperature log on the front of the refrigerator.

On March 21 at 2:30 PM a visual check of the PEG tube liquid nutritional supplements was conducted and found the following to be expired:
- Osmolite 1.2 calorie 8 oz #1 expired 12/11
- Perative 8oz #2 expired 5/11
- Optimental 8 oz #4 expired 10/12
- 2 Cal HN (2 calorie high nitrogen) 8 oz #5 expired 3/12

The Director of Nurses was shown the PEG tube formula and confirmed it was expired.

The facility failed to insure oral nutritional snacks and PEG tube formulas used for nutritionally compromised patients were served/administered in a manner to avoid harm secondary to use after expiration date.

Based upon record review and interview, the facility failed to ensure the time was documented on the physician progress notes on 10 of 14 ( #1, #2, #3, #5, #7, #8, #9, #12, #13, #14) medical records.

Review of medical records revealed the physician had failed to document the time of the entry on progress notes as follows:

Medical Record #1 - 20 entries
# 2 - 14 entries
#3 - 3 entries
#5 - 4 entries
#7 - 24 entries
#8 - 14 entries
#9 - 11 entries
#12 - 5 entries
#13 - 5 entries
#14 - 4 entries

An interview was conducted with the Chief Nursing Officer on 4/5/2012. The Chief Nursing Officer confrmed the entries had not been dated and this was an ongoing problem with physicians.

Based upon record review and interview, the facility failed to ensure the physician's orders had a documented time the order was written on 6 of 14 (#1, #2, #6, #7, #8, #9) medical records reviewed. The facility also failed to ensure verbal/telephone orders were dated, timed and signed by the ordering physician on 9 of 14 (#1 - #9) patients.

Record review of medical records revealed physician's orders failed to include the time the order was written as follows:

Medical Record #1 - 5 orders
Medical Record #2 - 9 orders
Medical Record #6 - 1 order
Medical Record #7 - 10 orders
Medical Record #8 - 9 orders
Medical Record #9 - 4 orders

Record review of medical records revealed verbal/telephone orders that had not been dated, timed, and signed by the ordering physician on the following:

Medical Record #1 - 5 orders
Medical Record #2 - 16 orders
Medical Record #3 - 7 orders
Medical Record #4 - 2 orders
Medical Record #5 - 1 order
Medical Record #6 - 4 orders
Medical Record #7 - 2 orders
Medical Record #8 - 3 orders
Medical Record #9 - 1 order

An interview was conducted with the Chief Nursing Officer on 4/5/2012. The Chief Nursing Officer confrmed the orders had not been dated and this was an ongoing problem with physicians documentation.

Based upon record review and interview, the facility failed to ensure the physicians authenticated verbal orders within 48 hours on 7 of 14 ( #3, #4, #5, #6, #7, #8, #9) records reviewed.

Review of physician's orders revealed verbal/telephone orders that had been written by a staff nurse and authenticated by the physician. The authentication was an electronic authentication but was not done within 48 hours. All authentications reviewed were done from 1-3 months after the order was written.
The findings were for the number of verbal/telephone orders found in the record that were not authenticated within 48 hours:

Medical Record #3 - 2 orders
Medical Record #4 - 9 orders
Medical Record #5 - 8 orders
Medical Record #6 - 4 orders
Medical Record #7 - 21 orders
Medical Record #8 - 12 orders
Medical Record #9 - 5 orders

An interview was conducted with the Chief Nursing Officer on 4/5/2012. The Chief Nursing Officer confrmed the orders had not been dated and this was an ongoing problem with physicians documentation.

Based on observation and record review, the facility failed to enforce policies that provide for a sanitary environment for patient care. 2 of 2 employees were found without proper personal protective equipment (PPE) in patient rooms. Six packing boxes were found in clean patient care areas.

Findings include:

Review of Infection Control Policy #1011, " Guidelines For Isolation Precautions, " section titled, " Contact Precautions, " revealed the following:
" Healthcare personnel should wear a gown and gloves when close interaction with the patient and/or environment is anticipated. "

On 3/20/12 at 11:05am, an employee was observed in direct contact with a patient in contact precautions. The employee was not wearing a cover gown as per policy.

On 3/22/12 at 10:00am, an employee was observed in direct contact with a patient in contact precautions. The employee was not wearing a cover gown as per policy.

During a hospital tour on 3/20/12 at 11:05am, four packing boxes were found on the floor in the 6th floor clean storage area. Two packing boxes were found in the respiratory therapy storage room.