HospitalInspections.org

U9352

[The items available must include the following:] Equipment and supplies commonly used in life
saving procedures, including airways,
endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters.


This STANDARD is not met as evidenced by: Based on observation, interview and policy review, the facility failed to monitor, restock, and remove outdated emergency supplies from one of one Malignant Hyperthermia (MH, a severe reaction to medication used during a surgical procedure, which can be life-threatening) cart. This deficient practice failed to ensure emergency supplies were immediately available and failed to ensure a safe environment for patients. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Malignant Hyperthermia," dated 11/2014, showed the pharmacy technician/pharmacist was responsible for checking the MH cart and if used the Pharmacy was to replenish the supplies.

2. Observation in the Operating Room (OR) medication room and concurrent interview with Staff PP, Registered Nurse (RN), Surgery Manager on 01/07/15 at 1:50 PM, of supplies contained in a cart identified as the MH cart showed:
- 12 blood collection tubes expired 2009;
- Six tubes for arterial blood testing expired 2010;
- Six skin temperature sensors (for reading body temperature), four expired in 2011 and two expired in 2013;
- Two Intravenous start trays (IV, insertion trays for medication into the vein), expired 2008;
- 10 IV catheters (tube used to administer medication into the vein), one expired in 2008, two expired in 2010, three expired in 2012, and four expired in 2013;
- One Urinary Catheter Tray (container holding supplies needed to drain urine from the bladder), expired 10/2010;
- 12 Syringes, expired 2012;
- 10 Needles, expired 2013.
Staff PP stated that the pharmacy technician was responsible to check the MH cart for expirations, remove outdates and restock.

3. During a phone interview on 01/13/15 at noon, Staff OOO, Pharmacist, stated that the pharmacy was responsible for the MH cart, but they only looked at the drugs and failed to look at the supplies.

U9352

[The policies include the following:]

A system for identifying, reporting, investigating and controlling infections and communicable diseases of patients and personnel.
This STANDARD is not met as evidenced by: Based on observation, interview, and policy review the facility failed to perform hand hygiene for seven patients (#3, #25, #1, #26, #28, #19, and #32) of 11 patients observed for hand hygiene. The facility also failed to ensure that staff not place clean supplies in an operating room (OR) for one patient (#27) of one patient until after completion of environmental cleaning/disinfection of the room. These deficient practices had the potential to increase the risk of cross contamination and placed all patients, visitors, and staff at risk for infection. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Hand Hygiene," dated 03/17/14, showed that staff were directed to perform hand hygiene:
- Before having direct contact with patients;
- After contact with a patient's skin;
- After contact with body fluids, mucous membranes and wounds;
- After contact with inanimate objects including equipment in the immediate vicinity of the patient; and
- After removing gloves.
The policy also showed that staff were expected to change gloves during patient care if moving from a contaminated body site to a clean body site.

Record review of the facility's policy titled, "Handwashing and Glove Use," dated 01/01/14, showed that staff were directed to use hand sanitizer prior to entering a patient's room and upon exiting a patient's room to prevent
cross-contamination. Proper use of disposable gloves included:
- Wash hands before putting on gloves or changing gloves;
- Wash hands after removing gloves; and
- Discard gloves when leaving the work area to get supplies and after touching inanimate objects and equipment.

Record review of the facility's policy titled, "Contact Precautions," dated 02/12/14, showed that contact precautions applied to patients with known or suspected infections that could be transmitted by direct or indirect contact. Staff were expected to perform hand hygiene and put on gown and gloves when entering a patient's room and discard before leaving a patient's room.

2. Observation on 01/06/15 at 10:10 AM showed Staff K, Occupational Therapist, entered Patient
#3's room labeled with Contact Precautions. She failed to:
- Perform hand hygiene before putting on gloves and a gown;
- Perform hand hygiene and put on new gloves after she touched and moved a clipboard outside of the patient's room, and with her contaminated hands she touched the skin of the patient's arms and hands;
Perform hand hygiene after she removed the gown and gloves when she left the patient's room and with her contaminated hands she walked across the hall, entered a room labeled "Nutrition Room," and washed her hands in the sink.

During an interview on 01/06/15 at 10:30 AM, Staff K, stated that she did not use hand sanitizer when she entered the patient's room because she was focusing on putting on the gown and gloves. She stated that she should have removed her gloves and used hand hygiene after touching her clipboard in the hallway. She acknowledged that Patient #3 had methicillin-resistant staphylococcus aureus (MRSA, an infection caused by a strain of bacteria that has become immune to common antibiotics), she touched his arms and hands while performing therapy, and she did not use hand sanitizer when leaving the room. She stated that she thought it was alright to wash her hands in the nutrition room across the hall.

During an interview on 01/06/15 at 10:40 AM, Staff D, Project Director, stated that staff were expected to use the hand sanitizer when they entered and left a patient's room. She also stated that the nourishment room was considered a clean area and it was not acceptable for staff to wash their hands in the room after caring for patients.

3. Observation on 01/07/15 at 10:00 AM showed Staff KK, Registered Nurse (RN), attempted to remove a urinary catheter for Patient #25. During the process she cleaned the perineal area (penis and surrounding area), failed to perform hand hygiene, and with her contaminated hands she held the clean portion of the catheter causing potential cross contamination.

During an interview on 01/07/15 at 10:25 AM, Staff KK, stated that she did not know why she had not performed hand hygiene, she didn't think about it. She confirmed that she should have performed hand hygiene and changed gloves when going from a dirty to clean process.

During an interview on 01/07/15 at 2:00 PM, Staff JJJ, Infection Preventionist, stated that:
- Staff were expected to follow facility policies and a document titled, "Your five moments of hand hygiene" by the World Health Organization; and perform hand hygiene before patient contact, before a clean task, after body fluid exposure risk, after patient contact, and after contact with patient surroundings.
-Staff were expected to perform hand hygiene and put on a new pair of gloves when going from a dirty area to a clean process during patient care.
-Staff were expected to perform hand hygiene and change gloves after touching inanimate objects and before touching food.

4. Observation on 01/06/15 at 9:26 AM, showed the following:
- Staff G, RN, failed to perform hand hygiene when entering/exiting Patient #1's room to collect medications and water on two separate occasions.
- Staff G handled many inanimate objects, and/or surfaces, without performing hand hygiene before she administered medications to Patient #1.
- Staff G failed to perform hand hygiene prior to handling a pill (Oyster Shell-calcium) with her bare contaminated hands to place the pill in a device to cut it in half.

During an interview on 01/07/15 at 1:40 PM, Staff G stated that she should have used foam hand sanitizer on her hands, "Foam in/foam out," with each entrance/exit of Patient #1's room. Staff G stated that she was in a hurry.

5. Observation on 01/06/15 at 3:51 PM, showed Staff R, Wound Certified Nurse, failed to change her gloves and perform hand hygiene after removing a dirty wound dressing, and before putting a clean wound dressing on Patient #1.

During an interview on 01/06/15 at 4:12 PM, Staff R stated that she should have changed her gloves and performed hand hygiene from the dirty portion to the clean portion of the dressing change.

6. Observation in the Operating Room (OR) on 01/07/15 at 10:00 AM, showed Staff LL, Certified Registered Nurse Anesthetist (CRNA), failed to remove gloves and perform hand hygiene after he injected medication into Patient #26's Intravenous (IV, into vein) line. Staff LL failed to remove gloves and pushed Patient #26's stretcher to the OR room. Staff LL continued to wear the same contaminated gloves during the anesthesia induction (placing a breathing tube into the patient's throat and into the windpipe).

During an interview on 01/07/15 at 12:30 PM, Staff LL, stated that he did not do hand hygiene and that he should have removed his gloves and done hand hygiene.

7. Observation in the OR and concurrent interview with Staff B, RN Chief Nursing Officer (CNO) on 01/07/15 at 10:40 AM, showed Staff SS, Medical Student, performed skin prep for Patient #28 (cleaned skin with cleanser) prior to surgery. Staff SS removed gloves and failed to perform hand hygiene after glove removal. Staff B verified lack of hand hygiene by Staff SS.

8. Record review of the facility's policy titled, "Nasopharyngeal (the upper part of the throat behind the nose) specimen collection," dated 04/04/14 showed the following direction for staff:
- After obtaining the specimen, remove the cap from the culture tube, insert the swab and break off the contaminated end.
- Close the tube tightly.
- Remove and discard gloves.
- Perform hand hygiene.
- Label the container.

9. Observation and concurrent interview on 01/06/15 at 4:10 PM, with Staff S, RN in the Emergency Department (ED) showed the following:
-Staff S failed to remove her gloves and perform hand hygiene after performing a nasal swab on Patient #19.
-Staff S removed an ink pen from her pants pocket with her gloved hand and labeled the specimen container then returned the contaminated ink pen to her pocket.
-Staff S stated that she didn't realize she had contaminated her ink pen with her dirty glove and that she should have removed her gloves first and performed hand hygiene before she used her ink pen.

10. Observation in Patient #32's room and concurrent interview on 01/07/15 at 9:10 AM showed Staff II, Medical Technologist, touched Patient #32 to check the patient's arm band and failed to perform hand hygiene. Staff II completed drawing blood and put her gloved hands into her pocket to obtain a marker. Staff II failed to remove gloves and perform hand hygiene prior to putting her hands in her pocket. Staff II stated that she typically completed this task in this manner; she drew blood infrequently, and was nervous.

11. During an interview on 01/08/15 at 8:15 AM, Staff B, CNO, stated that her expectation was for staff to follow the facility policy and procedure regarding hand hygiene and glove use.

12. Record review of the facility's undated policy "Environmental Cleaning", stated that staff should clean the operating room after each patient and when visible soiling occurs, by blood and body fluids as soon as possible.

13. Observation in the OR and concurrent interview with Staff OO and Staff B on 01/07/15 at 11:30 AM showed Staff NN, CRNA attached a clean tubing on the anesthesia machine for Patient #27, while OR staff cleaned the OR room. Red spots (identified as blood spots by Staff OO, RN) were visible on the OR floor next to the anesthesia machine from the prior surgical procedure. Staff OO, stated that anesthesia supplies should not be set-up in the OR room during cleaning of the room. Staff OO stated that the cleaner required a five minute dry time prior to room set-up for the next OR procedure. Staff B, CNO confirmed inappropriate placement of clean supplies in the unclean OR room.

U9352

[The policies include the following:]

Procedures that ensure that the nutritional needs of inpatients are met in accordance with recognized dietary practices and the orders of the practitioner responsible for the care of the patients, and that the requirement of §483.25(i) of this chapter is met with respect to inpatients receiving post CAH SNF care.

This STANDARD is not met as evidenced by: Based on observation, interview, record review and policy review the facility failed to ensure:
- Food served at appropriate cold temperatures;
- Opened food was labeled properly;
- Expired food removed from patient use; and
- Staff followed the policy for hand hygiene and cross contamination.
These deficient practices had the potential to cause cross contamination of foods and contribute to the possibility of food poisoning. The facility census was 10.

Findings included:

1. Record review of the US DHSS, PHS, FDA, 2013 Food Code directed the following in Chapter 3-501.16: Time/temperature control for food safety - cold foods should be served at 41 degrees Fahrenheit (F, measure of temperature) or lower.

Record review of the undated facility form titled, "Room Service Temperature Log," showed the standard for pudding should be less than or equal to 40 degrees F and milk should be less than or equal to 35 degrees F.

2. During an interview on 01/06/15 at 3:30 PM Staff V, Director of Dietary, stated that the hospital followed Hazard Analysis Critical Control Points (HACCP) and State food code guidelines and did not have a policy regarding temperatures of cold foods. He stated that the temperatures on the form cited above were from HACCP.

3. Observation and concurrent interview in the facility kitchen on 01/06/15 at approximately 11:45 AM showed chocolate pudding with a temperature of 42.5 degrees F and a carton of milk with a temperature of 44.1 degrees F. Staff Y, Compliance Officer and Staff DD, Lead/Caterer confirmed the findings.

During an interview on 01/06/15 at approximately 1:30 PM Staff V confirmed that the chocolate pudding and milk were too warm.

4. Observation on 01/06/15 at 2:00 PM of the refrigerator on the medical/surgical unit, Nourishment room, number 1744, showed eight milk cartons in the refrigerator, on a rack, in the door of the refrigerator. The temperature of the refrigerator was 40 degrees F. One of the milk cartons had a milk temperature of 43 degrees F. Staff Y and Staff DD, confirmed the findings.

5. Observation on 01/06/15 at 2:05 PM of the refrigerator on the medical/surgical unit, Nourishment room, number 1754, showed eight milk cartons in the refrigerator, on a rack, in the door of the refrigerator. The temperature of the refrigerator was 38 degrees F. One of the cartons of milk had a milk temperature of 43.4 degrees F. Staff Y and Staff DD confirmed the findings.

6. Record review of the Quality Assessment Performance Improvement for the Dietary Department showed monthly tray audits were completed for temperature accuracy, but failed to show which specific food items were inaccurate in order to track and trend what processes needed to be changed.

Record review of the facility's document titled, 'Food Services Meal Assessment," showed the tray audit form for staff to use. The form showed cold food and beverages were within guidelines if delivered at 50-55 degrees F and milk was within guidelines if delivered at 45 degrees F, contrary to the food code guidelines.

During an interview on 01/06/14 at 12:40 PM and 01/07/15 at 9:30 AM Staff V stated that milk and cold items must be kept at 41 degrees and that had always been their Dietary Department goal.

7. Record review of the facility's policy titled, "Dating and Labeling," dated 01/01/14, showed:
- Disposal dates will be written on each container prior to storage or serving.
- Disposal for all foods not addressed previously in this policy is four days.
- Write date food is to be disposed of or consumed by.

During an interview on 01/06/15 at 3:05 PM Staff V stated that there were no other policies for appropriate dating of dry foods, frozen foods, or refrigerated foods for baking.

8. Observation and concurrent interview on 01/06/14 from approximately 9:15 AM to 10:00 AM in the facility kitchen showed:
- In the storage room there was a package of ready to serve vanilla cream icing dry mixture opened and dated 12/12/14 and no disposal date. The expiration date on the package was 02/01/15. There was approximately one fourth of the contents left in the package.
In the storage room there was a package of dry vanilla pudding mix with an opened date of 01/05/14 and no disposal date. The expiration date was not visible on the package. There was approximately one third of the contents left in the package.
- In the storage room there was a package of dry chocolate pudding mix with an opened date of 01/05/14 and no disposal date. The expiration date was not visible on the package. There was approximately one third of the contents left in the package.
- In the refrigerator there was a 19 pound tub of pie filling opened with approximately 18 pounds left in the tub. There was no opened or disposal date on the tub. No expiration date visible on the tub.
- In the ice cream freezer was one bag of six, frozen chocolate chip cookies. The bag was dated 12/15/14 with no disposal date.
- In the ice cream freezer was one bag of five cinnamon rolls. The bag was not dated, but had a disposal date of 12/03/14.
- Observations of the dry food items were confirmed by Staff V, Staff Y, and Staff X, Lead (day shift) and the frozen food observation were confirmed by Staff Y and Staff X.
- Staff X stated that the dry goods, the apple pie filling, and the frozen items should have all had a date of when opened or for frozen when made, and a disposal date of a month later.

9. Record review of the facility's policy titled, "Handwashing and Glove Use," dated 01/01/14, showed:
- Staff were to wash their hands when visibly dirty or contaminated;
- Staff were to wash their hands before putting on gloves, and rewashed and new gloves applied after contamination.
Gloves must never be used in place of hand washing;
-Disposable gloves were used when handling fresh products that will not be cooked, and products that had been cooked with no further heat treatment;
- Extra care must be taken to prevent a false sense of security;
- Improperly used gloves carry a high risk for cross contamination, because worker may not be aware that gloves were contaminated and should be changed.

Record review of the US DHHS, PHS, FDA, 2013 Food Code directed the following in Chapter
2-301.14 that food employees shall clean their hands after touching bare human body parts; after handling soiled equipment and utensils; during food preparation as often as necessary to remove soil and contamination; before donning (putting on) gloves and after engaging in other activities that contaminate hands and in Chapter 3-304.15 that single use gloves shall be used for only one task, no other purpose and discarded when soiled or when interruptions occur in the operation.

10. Observation and concurrent interview on 01/06/15 at 10:05 AM and 1:45 PM in the Dietary Department showed an ice scoop sat in a basin on top of the ice machine. Staff X, Lead, stated that the ice scoop was stored in the basin on top of the ice maker, if the basin was in use then the ice scoop was stored/sat on top of the ice maker. The ice scoop was used by numerous Dietary staff to scoop ice for patient's drinks without being cleaned after each use. Staff X stated that the ice scoop was washed only on the weekends. Later Staff X stated that staff washed the ice scoop at other times, but there was no schedule to clean the ice scoop or evidence to show when the scoop was cleaned. The ice scoop was used to scoop ice for patient's drinks.

During an interview on 01/07/15, Staff JJJ, Infection Preventionist, stated that:
- The ice scoop should have been washed after each use and had it's own bin for storage.
- Hand hygiene should have been conducted before glove use when preparing and serving food.
- Hand hygiene and glove changes should occur after touching inanimate objects, such as a wrapper for hamburger buns.

11. Observation and concurrent interview on 01/06/15 at 10:08 AM showed Staff Z, Nutrition Assistant, came in from outside the cafeteria failed to wash hands, put on gloves and obtained clean utensils. Staff Z, stated that she should have performed hand hygiene when she entered the cafeteria.

12. Observation and concurrent interview on 01/06/15 at 10:10 AM in the Dietary Department showed Staff AA, Nutrition Assistant with gloves on making salads. She removed her gloves and then placed a sticker on the salad container. Staff BB stated that she should have performed hand hygiene after she removed her gloves.

13. Observation and concurrent interview on 01/06/15 at 10:20 AM in the Dietary Department showed Staff BB, Courier with gloves on. She removed the left glove and put bowls of lettuce in the refrigerator and then cleaned debris from her work area. Staff BB failed to perform hand hygiene when she removed her left glove. Staff BB stated that she used her right hand to put the food into the refrigerator and then wanted to clean her work area before she removed the right hand glove and performed hand hygiene.

14. Observation and concurrent interview on 01/06/15 at 10:25 AM in the Dietary Department showed Staff W, Cook, removed gloves and obtained a cooking utensil. She failed to perform hand hygiene after she removed her gloves. Staff W stated that she failed to perform hand hygiene because she thought she did not need to perform hand hygiene after she removed her gloves because she was not touching food.

15. Observation and interview on 01/06/15 at 11:30 AM in the Dietary Department showed Staff PPP, Cook, left her tray line to obtain hamburger buns opened the package of hamburger buns and later left the tray line to obtain a package of sandwich bread and both times touched the bread/buns and put the bread/buns on a patient's plate with the same gloves as she used to obtain and open the packages. Staff PPP failed to remove her gloves and perform hand hygiene after her tasks were interrupted and after Staff PPP touched the outside of the bags. Staff X, Lead (day shift), confirmed the observation of cross contamination.

16. During an interview on 01/06/15 at 10:45 AM Staff X, stated that staff should perform hand hygiene each time they came into the kitchen, prior to putting on gloves, and when they removed gloves.

U9352

A nursing care plan must be developed and kept current for each inpatient.

This STANDARD is not met as evidenced by: Based on observation, interview, record review and policy review, the facility failed to follow their care plan policy when staff failed to incorporate a nursing care plan that addressed all patient needs that included measurable goals and interventions for three (#1, #2, #4) of eight patients reviewed. This failure had the potential to deny all patients admitted to the facility care based on their individual needs. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Care Plans" dated 07/2011, showed the following:
- The care plan was an interdisciplinary approach to the plan of care for a patient and consists of a problem statement(s), goals and interventions.
- After admission all patients will have a general plan of care.
- If a care plan cannot be found related to the primary problem, individual problems can be added to the general plan of care.
- Each discipline is responsible for modifying the care plan based on assessments, reassessments and patient's need for further care, treatment or services.

2. Record review of Patient #1's History and Physical (H & P) dated 01/01/15, showed the patient was admitted on that date with a chief complaint of confusion and the patient's skin was warm, dry and intact.

Observation in Patient #1's room, and concurrent interview on 01/06/15 at 9:26 AM, showed the following:

- The patient had a large, bloody looking wound on his left forearm.
- Staff G, Registered Nurse (RN), stated that the patient had been thrashing around in his bed in the early morning of 01/05/15 and had hit his forearm on the bed's siderail, causing the wound.
- Staff failed to provide the patient with protection from the siderails as of this observation/interview.

Record review of the patient's care plan dated 01/01/15 showed that as of 01/06/15 at approximately 9:40 AM, staff failed to identify the actual skin impairment with a goal and interventions to prevent potential future harm to the patient's skin from thrashing.

During an interview on 01/06/15 at approximately 9:45 AM, Staff F, Vice President of Quality, confirmed the care plan should have been updated to include the patient's skin tear and any interventions to prevent future harm.

3. Record review of the facility's policy titled, "Pain Assessment" dated 11/11/14, directed staff to perform and document a complete pain assessment on admission, with any self report of pain or evidence of pain, and when monitoring the effectiveness of pain interventions or treatment modalities. Staff was directed to reassess the patient's pain level and if the patient was still in pain to alter the treatment plan as appropriate.

4. Record review of Patient #2's H & P dated 01/01/15, showed that the patient was admitted on the same date, with morbid obesity, significant other medical problems, and she was scheduled for surgery.

During an interview on 01/06/15 at approximately 9:40 AM, Patient #2, stated that she had a pain management problem on a day (she did not recall the date) after surgery that caused excessive pain and limited her mobility (ability to move around). She stated the problem included delays in getting right type of pain medication and at the time she needed it.

Record review of Patient #2's medication record from 01/01/15 to 01/06/15, and during a concurrent interview on 01/06/15 at 3:00 PM, Staff Z, RN, confirmed that the medication record on 01/03/15 showed no consistent documentation of pain assessment, medication administration, and reassessment of pain to show that her pain was effectively managed.

Record review of Patient #2's care plan and concurrent interview on 01/06/15 at approximately 3:00 PM, Staff N, RN, stated that the care plan showed no problem, goals and interventions to to effectively manage pain.

During an interview on 01/08/15 at approximately 10:45 AM, Staff OOO, RN stated that it was expected to update the patient's care plan when there were problems with pain management and monitor until pain was relieved.

5. Record review of Patient #4's H & P dated 01/05/15, showed the patient was admitted on the same date for observation of dizziness and hypertension. The patient's blood pressure was 198/74 (120/80 normal blood pressure for adults) earlier upon arrival to the Emergency Department (ED).

Record review of the nursing flow sheets showed seven abnormal (high) blood pressure readings during her hospitalization ranging from 140/50 to 208/88.

Record review of the patient's Care Plan dated 01/05/15 showed no individualized plan of care in relation to her hypertension.

During an interview on 01/06/15 at 2:10 PM, Staff E, RN, Director of Medical/Surgical, stated that she would have expected the patient's hypertension to be included in her plan of care.

During an interview on 01/08/15 at 8:15 AM, Staff B, Chief Nursing Officer, (CNO), stated that her expectation was for complete care planning based on the patient's needs/problems.

U9352

The CAH has an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The program requires that-

all patient care services and other services affecting patient health and safety are evaluated.


This STANDARD is not met as evidenced by: Based on interview, record review, and policy review the facility failed to ensure patient care services provided were evaluated by the governing body by not providing individual department Quality Assessment Performance Improvement (QAPI) data during the three past quarters of 2014 (04/16/14, 07/16/14, and 10/15/14) of three reviewed. This practice could lead to substandard care for all patients, if patient care QAPI was not evaluated. The facility census was 10.

Findings included:

1. Record review of the facility's policy titled, "Plan for the Provision of Patient Care," dated 06/2002, showed the organizational leadership included the governing body that was responsible for ensuring uniform delivery of patient care services provided throughout the facility.

Record review of the facility's undated document titled, "Confidential Governing Board Quality Report 2014, showed no review of the individual department QAPI.

Record review of the facility's undated document titled, "Quality and Safety Report for October 2014, showed no review of the individual department QAPI.

Record review of the facility's governing body minutes for 04/16/14, 07/16/14, 10/15/14 showed no report of the individual department QAPI.

2. During an interview on 01/08/14 at approximately 8:00 AM Staff F, Vice President (VP) of Quality, stated that the governing body received no QAPI from the individual departments of the hospital at anytime during the year.

During an interview on 01/08/14 at 8:12 AM Staff A, Chief Executive Officer (CEO) stated that he was considered a governing body member and they did not review the individual QAPI for each department. He stated that the governing body relied on the medical staff involved in the QAPI program.

3. Record review of a facility report titled, "Infection Prevention and Control Plan" for 2014 showed:
- A need for hand hygiene surveillance due to low hand hygiene compliance and a high risk for infections;
- An organizational goal to use appropriate hand hygiene to 90% or greater compliance.
- The goal was not met and there was only sporadic compliance.
- Monthly hand hygiene surveillance results would be submitted to nursing and other key stakeholders, such as the governing body.

Record review of a report titled "2014 Performance Improvement Plan" showed an indicator for hand hygiene surveillance to be conducted to ensure compliance to 90%. Results of hand hygiene surveillance was 85% for first quarter (January to March), 75% for second quarter (April to June), 58% for third quarter (July to September) and 65% for fourth quarter (October to December). The report showed no specific plan to improve results to meet the goal of 90% compliance.

During an interview on 01/07/15 at 2:00 PM, Staff JJJ, Infection Preventionist, stated that:
- Hand hygiene surveillance observations were conducted about 20 times per month.
- Observations were conducted to assess staff's expectation to use hand sanitizer when entering and when leaving a patient's room.
The monthly hand hygiene compliance worksheet for 2014 had results of 62% compliance for October, 79% for November, and 60% for December; and the report was not submitted to the governing body.
- The "2014 Performance Improvement Plan for Infection Control" had quarterly results and was only used within the department and not forwarded to committees or the governing body.

During an interview on 01/08/15 at 10:55 AM, Staff A, CEO, stated that he and the governing body were not given reports about the low compliance of hand hygiene surveillance.

U9352

[The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter:]

(1) Resident rights (§483.10(b)(5) & (6)):

§483.10(b)(5) The facility must-

(i) Inform each resident who is entitled to Medicaid benefits, in writing, at the time of admission to the nursing facility or, when the resident becomes eligible for Medicaid of-

(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;

(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and

(ii) Inform each resident when changes are made to the items and services specified in paragraphs (5)(i) (A) and (B) of this section."

§483.10(b)(6) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate."

This STANDARD is not met as evidenced by: Based on interview and record review the facility failed to provide written notification of possible charges incurred during a Swing Bed (a specific portion of the hospital that provides skilled services and receives a different reimbursement based on that level of care) stay for one discharged patient (#7) of one discharged patient reviewed. This had the potential to affect all Swing Bed patients admitted and could cause financial hardship via receipt of an unexpected bill after discharge for services. The facility Swing Bed census was zero during this survey.

Findings included:

1. Even though requested, the facility failed to provide a policy regarding this requirement.

2. Record review of discharged Patient #7's History and Physical (H & P) dated 01/02/15, showed the patient was admitted to a Swing Bed on that date with a diagnosis of pneumonia.

Record review of the patient's record showed staff failed to provide written notification of potential charges while a Swing Bed patient.

During an interview on 01/07/15 at 9:03 AM, Staff E, Swing Bed Coordinator, stated that she was not aware of any written notification of potential charges to Swing Bed patients prior to admission, or periodically during stay. Staff E confirmed there was no policy regarding this requirement.

During an interview on 01/07/15 at 12:40 PM, Staff E, confirmed notification of potential charges was not currently being provided to Swing Bed patients.

During an interview on 01/08/15 at approximately 9:30 AM, Staff F, Vice President of Quality, stated that they did not have a current policy that addressed this requirement and the facility did not provide notification of possible charges to Swing Bed patients.