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Based on record review and interview, the hospital failed to ensure the effective implementation of the grievance process by failing to follow their policy/procedure relating to the grievance process after complaints/concerns were brought forward by the family of a patient and by the physician at Hospital B regarding the care and services provided to 1 of 3 patients (Patient #5) reviewed for the effectiveness of the grievance process out of a total sample of 12 patients. Findings:

Review of the Interdisciplinary Progress Notes revealed an entry dated 2/03/11 at 2:0 p.m. entered by S13 (Case Manager) which documented "Spoke to (name of patient's son) pt son had concerns that his sister (name of patient's daughter) had called him about. These concerns were forwarded to (S14) (DOC-Director of Case Management) also pt. son (name) # was given to CNO (S2) for follow up". In an interview on 5/10/11 at 11:55 a.m. S13 indicated that Patient #5's son had voiced concerns about "care issues" involving Patient #5. S13 indicated that she forwarded the concerns to S14 (Director of Case Management). S14 was unavailable for interview as she was out on leave during the survey. Review of the physician progress notes revealed an entry dated 2/08/11 which indicated that the family was requesting for Patient #5 to be transferred to another LTAC. Documentation revealed that the patient was evaluated and not accepted by the other facility.

Review of an Incident Report dated 2/11/11 revealed that a physician from Hospital B (S22) called Meadowbrook Specialty Hospital of Lafayette at 8:35 a.m. and reported that Patient #5 was "severely dehydrated" and in "deplorable condition" upon his arrival to Hospital B's ED (Emergency Department) on 2/11/11. Documentation revealed that S22 reported that "it showed poor care on your end".

Review of another Incident Report dated 2/21/11 related to Patient #5 revealed that a lady was placing flyers on cars at a nearby Wal-Mart which indicated "Meadowbrook neglected my dad now he is in a coma at (Hospital B)".

S6 (Quality Director) was interviewed on 5/09/11 at 1:30 p.m. S6 reported that all grievances are handled by the Quality Department. S6 reported that she was not aware of any grievances regarding the care and services provided to Patient #5. S6 reported that she could provide no documentation to indicate that an investigation had been conducted into the care and services provided to Patient #5.

Based on record review and interview, the registered nurse failed to supervise and evaluate the care provided to patients by:

1. Failing to notify the physician and/or practitioner in a timely manner of a change in the respiratory status of 1 of 2 patients (Patient #5) reviewed for change in status out of a total sample of 12 patients. Findings:

Patient #5: Medical record review revealed that Patient #5 was admitted to Meadowbrook Specialty Hospital of Lafayette on 1/22/11 at 5:15 p.m. Review of the History and Physical dated 1/22/11 at 7:31 p.m. revealed "This is an 83-year-old white male who suffered a stroke in the past and also underwent treatment for encephalopathy by Dr. (name) at (Hospital A). The patient also underwent PEG tube placement from Dr. (name). The patient is doing well, and the PEG tube is flushing fine. He is in need of physical therapy due to his severe deconditioning. He will also need occupational therapy, as well as nursing care. The patient is very cachectic with bilateral bitemporal wasting". Further review revealed the assessment data was "1. Deconditioning. 2. Aspiration Pneumonia. 3. Dyspnea. 4. Dysphagia. 5. Encephalopathy. 6. Moderate protein-calorie malnutrition. 7. Chronic cough, which has apparently been getting better after PEG tube placement".

Review of the nursing notes revealed no documentation to indicate Patient #5 had been experiencing rapid/shallow respirations and no documentation to indicate that Patient #5's respiratory rate had exceeded 26 breaths per minute prior to 2/10/10. Documentation revealed an entry dated 2/10/10 at 7:05 p.m. that read "Pt assessed per resp. Pt rapid/shallow breaths noted. Pt eyes closed. Eyes open when name called. Pt with resp 36. Breathing tx. Atrovent administered. 02 sat 90% / 4L min 02". There was no documentation to indicate the physician/practitioner was notified on 2/10/11 of Patient #5's change in condition relating to the respiratory rate of 36 breaths per minute. In addition, there was no documentation to indicate the physician/practitioner had ordered for the 02 flow rate to be increased to 4 Liters per minute. Documentation revealed an entry dated 2/11/11 at 8:00 a.m. that read "Lethargic. Pt with eyes closed. Skin W/D (warm/dry) to touch. Pt nonverbal. Pt with 02 at 5L/min via NC. Pt respirations rapid and shallow. 34 min. 02 sat 94%. Resp therapy aware. Dr. (S12) paged. Pt OOB (with) PT/OT (name) Pt ambulated short distance in gym therapy. (PT) notified per resp r/t exertion and respirations. Pt lying in bed. Notified Dr. (S12) r/t (change) in level of consciousness and respirations. ABG's and chest x-ray ordered. Dghtr aware and verbalized understanding. Will continue to monitor". Documentation revealed an entry dated 2/11/11 at 9:45 a.m. that read "Pt transferred to bed. Pt resting quietly. 02 at 5L/min, 02 sat 94% pt eyes open, W/D to touch". Documentation revealed an entry dated 2/11/11 at 3:25 p.m. that read "Dr (S12) here and assessed pt. stated 'I want him transferred to ER for a workup he has changed' Notified dghtr per Dr. (S12). Family request (Hospital B). Documentation revealed an entry dated 2/11/11 at 4:05 p.m. that read "(Ambulance Service Provider A) in room and pt on stretcher with nasal intubation per (Ambulance Service Provider A). Paramedic stated 'He was breathing 33 a minute but he just dropped down to 4' Pt. with (RRT) at side. Pt. transferred to (Hospital B)".

S6 (Director of Quality) was interviewed on 5/12/11 at 4:30 p.m. When asked if there was any documentation in the medical record to indicate the physician and/or practitioner was notified of the change in Patient #5's respiratory status as documentation on 2/10/11 at 7:05 p.m. indicated that his respirations were rapid and shallow and his respiratory rate was 36 breaths per minute, S6 reported that there was no documentation to indicate that the physician/practitioner was notified of the change in Patient #5's respiratory status on 2/10/11. When asked if there was any documentation to indicate that the registered nurse had reassessed Patient #5's respiratory status throughout the night of 2/10/11 and early a.m. of 2/11/11, S6 reported that there was no documentation to indicate that the registered nurse had reassessed the respiratory status of Patient #5 after his respirations were found to be rapid and shallow with a respiratory rate of 36 until 8:00 a.m. on 2/11/11. When asked if there was any documentation to indicate that the physician and/or practitioner had ordered for the O2 rate to be increased to 4 liters per minute or 5 liters per minute, S6 reported that she did not see any orders to increase the O2 rate.

S12 (Attending Physician) was interviewed on 5/11/11 at 11:50 a.m. S12 reviewed the medical record of Patient #5. S12 reported that she met with the patient on 1/24/11, 1/25/11, 1/26/11, 1/27/11 and 2/11/11. S12 reported that she received a call from the nurse on the a.m. on 2/11/11 who reported that the patient was less responsive, not as alert, and had shallow respirations. S12 reported that ABG's and a chest x-ray were ordered. S12 reported that she evaluated Patient #5 on the afternoon of 2/11/11 and decided to transfer him to Hospital B for evaluation and treatment. S12 reported that there was a significant change in Patient #5's condition from when she had last seen him on 1/27/11. S12 reported that she contacted the physician (S11) who assessed Patient #5 on 2/10/11 and he informed her that he did not see the significant change at the time of his meeting with the patient. S12 reported that (Ambulance Service Provider A) was called to transport Patient #5 to Hospital B. S12 reported the paramedics performed a nasal intubation on Patient #5 after transferring him to the rolling stretcher and that Patient #5 was then taken to Hospital B. S12 reported that she was not aware of any complaints filed on behalf of the patient. S12 reported that she would not attempt to block a transfer if a patient or family member was requesting to be transferred.

The medical record relating to Patient #5's hospitalization at Hospital B was reviewed. Review of the ED (Emergency Department) record revealed that Patient #5 arrived at Hospital B's ED (Emergency Department) on 2/11/11 at 4:25 p.m. Patient #5 was transported from Meadowbrook Specialty Hospital of Lafayette to Hospital B by Ambulance Service Provider A. Further review of the ED record revealed the ED physician documented a Final Impression of Respiratory Failure, ARF secondary to Dehydration, and Sepsis. Patient #5 was nasally intubated upon arrival to Hospital B. Documentation revealed that Patient #5 was orally intubated while in the ED at Hospital B. Documentation revealed that Patient #5 was admitted to an inpatient unit at Hospital B on 2/11/11.


2. Failing to ensure that the orders of the physician and/or practitioner were followed for 2 of 12 sampled patients. Findings:

Patient #5: Medical record review revealed that Patient #5 was admitted to Meadowbrook Specialty Hospital of Lafayette on 1/22/11 at 5:15 p.m. Review of the physician's orders revealed admission orders dated 1/22/11 at 3:00 revealed an order for weights to be obtained on admission and weekly thereafter. Further review of the physician orders revealed an order dated 2/08/11 at 7:30 p.m. to administer bolus tube feedings of Glucerna 1.5, 1 can, 6 times per day at 8:00 a.m., 11:00 a.m., 2:00 p.m., 5:00 p.m., 8:00 p.m. and 11:00 p.m. There were no orders to discontinue or to hold the bolus tube feedings.

Review of the medical record including the graphic record revealed no documentation to indicate that a weight was obtained on Patient #5 on admission as ordered. Review of the graphic record revealed the first documented weight of Patient #5 during his hospitalization at Meadowbrook Specialty Hospital of Lafayette was on 1/24/11 (day 3 of his hospitalization). Documentation in the medical record revealed the following weights for Patient #5: 1/24/11- weight of 111.6 pounds; 2/02/11- weight of 168.4 pounds (revealing a weight gain of 56.8 pounds in 9 days); 2/08/11- weight of 107.3 pounds (revealing a weight loss of 61.1 pounds in 6 days). There was no documentation to indicate that Patient #5 was re-weighed on 2/02/11 in order to determine if the documented weight of 168.4 pounds was accurate which indicated that Patient #5 had gained 56.8 pounds in 9 days. There was no documentation to indicate that any member of the treatment team including the registered nurse, registered dietician or physician had identified Patient #5's documented weight gain/weight loss as an area that needed to be assessed and/or evaluated and there was no documentation to indicate that any member of the treatment team questioned the accuracy of the documented weights obtained on Patient #5.

The hospital's policy/procedure titled "Patient Weights" was reviewed. The policy/procedure documents "Patients weights will be monitored in order to determine effectiveness of prescribed diets and pathophysiologic conditions, which may alter weight". The policy/procedure further documents "Weights will be obtained on admission, including transfers in, and weekly. Some patients may require weights more frequently as ordered by the physician" and "Staff will review the patient's previous weight prior to weighing the patient" and "Weights will be documented on the patient's graphic record. The attending MD and dietary will be notified of a five pound increase or decrease".

S9 (Registered Dietician-Director of Nutritional Services) was interviewed on 5/06/11 at 1:15 p.m. S9 reviewed the medical record of Patient #5. S9 reported that she conducted a nutritional consult on Patient #5 on 1/23/11. S9 confirmed that there was no documentation to indicate that a weight had been obtained on Patient #5 upon his admission to Meadowbrook Specialty Hospital of Lafayette. S9 reported that a weight should have been obtained on admission. S9 confirmed that the first documented weight was on 1/24/11 which indicated that Patient #5' weight was 111.6 pounds. S9 confirmed that the next documented weight was on 2/02/11 which indicated that Patient #5's weight was 168.4 pounds. S9 confirmed that this documentation indicated that Patient #5 had a weight gain of 56.8 pounds in 9 days. S9 confirmed that the next documented weight was on 2/08/11 which indicated that Patient #5 had a weight loss of 61.1 pounds in 6 days. S9 reported that she did not feel that the documented weights were accurate. S9 confirmed that there was no documentation to indicate that Patient #5 was re-weighed on 2/02/11 in order to determine if the documented weight of 168.4 pounds was accurate. S9 confirmed that there was no documentation to indicate that any member of the treatment team including the registered nurse, registered dietician or physician had identified Patient #5's documented weight gain/weight loss as an area that needed to be assessed and/or evaluated.

S17 (Registered Nurse) was interviewed on 5/10/11 at 1:20 p.m. S17 reviewed the medical record of Patient #5 and reported that she did remember the patient. S17 reported that she was the nurse who admitted Patient #5 to Meadowbrook Specialty Hospital of Lafayette on 1/22/11 at approximately 5:00 p.m. S17 reported that she was involved in the care provided to Patient #5 on 1/22/11, 1/23/11, 1/26/11, 2/04/11, and 2/07/11. S17 confirmed that there was no documentation to indicate that a weight had been obtained on Patient #5 on admission as ordered.

S19 (Registered Nurse) was interviewed on 5/11/11 at 10:00 a.m. S19 reviewed the medical record of Patient #5. S19 reported that there was no documented weight upon Patient #5's admission. S19 indicated that she did not feel that the documented weights were accurate. S19 confirmed that there was no documentation to indicate that any member of the treatment team including the registered nurse, registered dietician or physician had identified Patient #5's documented weight gain/weight loss as an area that needed to be assessed and/or evaluated.

Review of the medical record including the graphic records and the intake & output records failed to provide evidence to indicate the tube feedings were administered to Patient #5 on 2/11/11 as ordered by the physician. Documentation on the graphic record revealed no evidence to indicate that Patient #5 received the 8:00 a.m. bolus tube feeding on 2/11/11, the 11:00 a.m. bolus tube feeding on 2/11/11, or the 2:00 p.m. bolus tube feeding on 2/11/11. In addition, there was no documentation to indicate that any fluids and/or nutrients were provided to Patient #5 on 2/11/11.

The hospital's policy/procedure titled "Enteral Feeding via Gastrostomy Tube" was reviewed. The policy documents "It is the policy of Meadowbrook Specialty Hospital to ensure that Registered Nurses and Licensed Practical Nurses will implement a plan of care for the delivery of nutrients via Gastrostomy tube as ordered by a physician".

In an interview on 5/06/11 at 1:15 p.m., S9 (Registered Dietician-Director of Nutritional Services) reported that she conducted a nutritional consult on Patient #5 on 1/23/11. S9 confirmed that Patient #5 was on a NPO status and receiving nutritional support by tube feedings provided through a PEG tube. S9 confirmed that there was no documentation in the medical record to indicate the tube feedings were administered to Patient #5 on 2/11/11 as ordered as there was no evidence to indicate that Patient #5 received the 8:00 a.m. bolus tube feeding on 2/11/11, the 11:00 a.m. bolus tube feeding on 2/11/11, or the 2:00 p.m. bolus tube feeding on 2/11/11. S9 also confirmed that there was no documentation to indicate that any fluids and/or nutrients were provided to Patient #5 on 2/11/11.

In an interview on 5/10/11 at 12:35 p.m., S15 (Registered Nurse) reported that she was the charge nurse on the day shift on 2/11/11. S15 reviewed the medical record of Patient #5 and confirmed that there was no documentation to indicate the tube feedings were administered to Patient #5 on 2/11/11 as ordered as there was no evidence to indicate that Patient #5 received the 8:00 a.m. bolus tube feeding on 2/11/11, the 11:00 a.m. bolus tube feeding on 2/11/11, or the 2:00 p.m. bolus tube feeding on 2/11/11. S15 also confirmed that there was no documentation to indicate that any fluids and/or nutrients were provided to Patient #5 on 2/11/11. S15 confirmed that there was no documentation in the medical record to indicate that the tube feedings were to be discontinued on 2/11/11 and no documentation to indicate that the tube feedings were to be held on 2/11/11.


Patient #1: Review of the Medical Records for Patient #1 revealed the patient was admitted on 04/14/11 with an admitting diagnoses of Mitral Valve Endocarditis. Review of the Physician's Orders dated 04/21/11 at 8:15 a.m. revealed an order to Transfer patient to Hospital A ER (Emergency Room) for resp (respiratory)distress. Further review of the Physician's Orders revealed an order dated and timed 04/21/11 at 10:13 a.m., Stat echo, hold KUB (Kidney,Ureter, and Bladder) until MD (Medical Doctor) assess on rounds, consult Dr. F..... for pulmonology. Review of a Physician Order dated and time 04/21/11 at 12 p.m. revealed 1) Clarification: I did not hold transfer. Transfer was held by Administration. The Physician's Order was signed by S12MD. Another order was written by S12MD on 04/21/11 at 12:30 p.m. for a CT of Chest for PE (Pulmonary Emboli) protocol for hypoxia and tachycardia. There was no Physician's Order to hold the transfer to Hospital A's ER.

An interview was conducted with S12MD on 05/11/11 at 11:55 a.m. She stated a nurse contacted her on 04/21/11 and informed her Patient #1 was requiring more oxygen and currently was on a nonrebreathing mask at 100%. S12MD stated she gave the order on 04/21/11 at around 8 a.m. to transfer the patient to Hospital A's Emergency Room. She further stated she received another call from the nurse who stated administration said they could handle the patient's issues in the facility and had blocked the transfer. S12MD stated since the patient was still at the facility, she ordered a stat echo,a pulmonary, and cardiology consult. At 12 p.m. she stated she examined the patient and instructed the nurse to try to transfer the patient to the LTAC (Long Term Acute Care) at Hospital A, but a physician would not accept the patient. A CT scan was ordered and the patient was sent to Hospital C for the CT scan and the patient was admitted to Hospital C after the CT scan.

An interview was conducted with S20RN on 05/11/11 at 1 p.m. He stated he was the Nurse Manager of the unit Patient #1 was on when S12 MD wrote the physician's order to transfer Patient #1 to the emergency room at Hospital A. He went on to state the transfer was not held or blocked by administration, it was simply a misunderstanding. He stated he entered his unit at about 7 a.m. on 04/21/11 and was told Patient #1 was having some shortness of breath. At about 7:40 a.m. the cardiologist examined the patient and didn't voice any concerns about the patent's condition. When I was told the patient's nurse, who was a LPN, had called the doctor and the doctor wanted the patient transferred to the emergency room due to respiratory problems, I requested the charge nurse to assist the nurse and make sure S12MD was given an accurate picture of the patient. He further stated since the cardiologist had just left the patient's room without any concerns with the patient's condition, S20RN stated he was concerned the LPN had not given S12MD an accurate assessment of the patient. He stated the transfer was not blocked by administration, he was the person that directed the charge nurse to make sure an accurate assessment was given to S12MD. In hindsight he stated he should have spoken to S12MD directly to clear up any misunderstanding. He went on to state he did attempt to get in touch with S12MD twice since the incident to no avail to clear up the misunderstanding.

Based on record review and interview, the hospital failed to ensure that all entries entered into the medical record were authenticated, timed and/or dated. This was noted in 2 of 5 medical records (#1 & #4) reviewed for the authentication of entries in the medical record out of a total sample of 12 patients. Findings:
Review of the hospital ' s Policy for HIM (Health Information Management): Physician Requirements in part revealed " 1. All verbal/telephone orders must be dated, timed, and authenticated within 48 hours ... "
Patient #1: Medical record review revealed the patient was admitted to the hospital on 04/14/11. Review of the medical record revealed verbal orders dated 4/18/11 at 3:30 p.m., 4/19/11 at 6:45 p.m., 4/20/11 6:30 a.m., 4/20/11 at 2:30 p.m., and 4/20/11 at 3:55 p.m. that were not signed by the ordering practitioner.

An interview was conducted with S6Quality Assurance on 05/10/11 at 12:15 p.m. She confirmed the verbal orders were not signed by the ordering physician and their policy was the physician had 48 hours to sign verbal orders and 30 days for procedure notes and consultation notes to be signed by the physician.

Review of the Hospital ' s policy for HIM: Physician Requirement revealed in part " ..Records shall be completed and authenticated within thirty (30) days following patient discharge.. "

Patient #4: Medical record review revealed the patient was admitted to the hospital on 01/27/11. Review of the medical record revealed a Consultation dated on 02/02/11 that was by not signed by the consulting practitioner.

An interview was conducted with S6Quality Assurance on 05/10/11 at 12:15 p.m. She confirmed the consultation dated on 02/02/11 was not signed by the consulting practitioner.

Based on record review and interview, the hospital failed to ensure the discharge summary included documentation relating to a significant event that occurred during the hospitalization of 1 of 5 patients (Patient #5) sampled for discharge summaries out of a total sample of 12 patients. This was evidenced by the absence of documentation relating to the patient being nasally intubated by the ambulance service provider prior to being transferred out of the hospital in route to the ED (Emergency Department) at Hospital B. Findings:

The medical record of Patient #5 was reviewed. Review of the nursing notes revealed an entry dated 2/11/11 at 4:05 p.m. that documented "(Ambulance Service Provider A) in room and pt on stretcher with nasal intubation per (Ambulance Service Provider A). Paramedic stated 'He was breathing 33 a minute but he just dropped down to 4' Pt. with (RRT) at side. Pt. transferred to (Hospital B)".

Review of the Discharge Summary dated 2/11/11 at 4:26 p.m. revealed the patient's discharge diagnoses as "1. Status post treatment for aspiration pneumonia. 2. Dysphagia. 3. Dementia. 4. Clostridium difficile, for which he is being treated". The "Hospital Course" was documented as "Today, when I went to evaluate the patient, he is much different than when I saw him a few weeks ago. He is breathing comfortably. He responds to pain, but he does not follow commands. The nursing staff states that his vital signs have been stable all day. Thus, I had a discussion with the patient's family, and we are going to transfer him to an acute care hospital. The most recent vital signs showed temperature was 97.6, blood pressure 143/87, pulse 103, and respirations were 22. General; the patient is a thin, elderly male. He was in no apparent distress. He only responded to pain. Cardiovascular showed heart was a regular rate and rhythm. There was no edema. Lungs were actually clear to auscultation bilaterally. The abdomen was soft with positive bowel sounds. It was nondistended. Extremities showed no clubbing, cyanosis, or edema. Labs, a chest x-ray done today was normal. He also had an ABG done that showed no significant abnormality". The "Plan" was documented as "We will transport the patient by ambulance to the emergency room. I will initiate some IV fluids at this time considering that the patient was recently diagnosed with Clostridium difficile and he may be dehydrated. Hopefully, he will be transferred to an acute care facility where he can get a further workup including a CT of the head and other studies such as cultures. He will be admitted to the hospital for observation and treatment".

Documentation on the Discharge Summary failed to include information relating to the patient undergoing a nasal intubation by Ambulance Service Provider A while still in Meadowbrook Specialty Hospital of Lafayette.

In an interview on 5/11/11 at 11:50 a.m., S12 (Attending Physician) confirmed there was no documentation on the Discharge Summary to indicate that Patient #5 was nasally intubated prior to leaving Meadowbrook Specialty Hospital of Lafayette.

Based on observations and interviews, the hospital failed to ensure that all facilities, supplies, and equipment was maintained in a manner to ensure an acceptable level of safety and quality. Findings:

Observations of the Patient Rooms on 5/06/11 between 9:00 a.m. and 9:45 a.m. revealed the following:
? Patient Room #104-toilet paper was stuffed under the nursing call system button in this room. Paper prevented the call system was being inadvertently activated by holding the call button in the up position as the call system button was loose and would fall and self activate unless being held up by something as in this case-toilet paper.
? Patient Room #104- three (3) bathroom tiles missing from the wall.
? Patient Room #104- dark discoloration measuring 6 inches by 8 inches on the bathroom floor near the shower drain. The discoloration had a mildew/mold appearance. In an interview with the Infection Control Coordinator (S8) at the time of this observation, S8 confirmed that the dark discoloration had a mildew/mold appearance.
? Patient Room #202- Room reported to be clean and ready for a new patient. Waste was noted to be in the red biohazardous waste container in this room as the container was 1/3 full of soiled items.
? Patient Room #202- Room reported to be clean and ready for a new patient. A dried sticky residue (clear in color) was noted on the pulse oximeter in this room and a dried residue (tan in color) was noted on the hand-rail of the bed.
? Patient Room #201- Room reported to be clean and ready for a new patient. A dried residue (brownish red in color) was noted on the hand-rail of the bed

The above findings were confirmed by the Nurse Manager and the Infection Control Coordinator at the time of the observations.

Observations of the therapy gym on 5/06/11 between 9:45 a.m. and 10:00 a.m. revealed the following:
? Therapy Table- Rips/tears noted on the surface area of the table. Duct tape was noted to be covering some of the rips/tears on this table.
? Tilt Table- Rips/tears noted on the surface area of the table. Sections of clear tape and blue tape were noted to be covering some of the rips/tears on this table.
? Cardiac Chair- Rips/tears noted on the surface area of the Cardiac Chair.

The above findings were confirmed by the Director of Therapy Services and by the Infection Control Coordinator at the time of the observation.

Based on record review and interview, the hospital's Infection Control Officer failed to ensure the effective implementation of a system for investigating and/or controlling infections by: 1) failing to ensure hospital employees and non-employee physicians had annual Tuberculosis (TB) screening and/or documented evidence that these screenings were in compliance with the CDC (Centers for Disease Control) guidelines as evidenced by 3 of 3 physician credentialing files having no evidence of TB screening within the past year (S10MD, S11MD, S12MD) and 3 of 4 nurses having TB skin tests with no documented evidence the TB skin tests were read within the CDC guidelines of 48 - 72 hours (S13LPN, S14RN, S16RN) and 2) failing to have a system in place to ensure that all staff members comply with educational trainings/inservices relating to the identification, reporting, and controlling of infections and communicable diseases that have been mandated and/or deemed necessary by the hospital's infection control department. Findings:

1. Failing to ensure hospital employees and non-employee physicians had annual Tuberculosis (TB) screening and/or documented evidence that these screenings were in compliance with the CDC (Centers for Disease Control) guidelines. Findings:

Review of 3 of 3 physician credentialing files revealed no documented evidence of annual current TB screening for physician S10MD, S11MD, and S12MD.

In an interview on 05/06/11 at 1:45 p.m. these findings were confirmed by S3 Medical Staff Credentialing.

In an interview on 05/06/11 at 2:05 p.m. with S2DON she confirmed that there was no documented evidence in the credentialing files of physicians S10MD, S11MD, and S12MD of current TB testing.

Review of the personnel records for S13LPN, S14RN, and S16RN revealed the forms used by the hospital to document TB skin tests had no documentation to indicate the time the skin test was placed and the time it was read.

In an interview on 05/06/11 at 12:45 p.m. these findings were confirmed by S8RN, Infection Control. She further confirmed that without documentation to indicate the time the skin test was placed and the time it was read it cannot be confirmed that the test was read within the 48 - 72 hour time frame per CDC Guidelines.

Review of a CDC (Center for Disease Control) Recommendation and Report , 54(RR17); 1-141, document dated December 30, 2005 titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005" revealed the following: "HCW's (Health Care Workers) who Should Be Included in a TB Surveillance Program." "HCW's refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. Part time, temporary, contract, and full-time HCW's should be included in TB screening programs. All HCW's who have duties that involve face to-face contact with patients with suspected or confirmed TB disease (including transport staff) should be included in a TB screening program. The following are HCW's who should be included in a TB screening program: Administrators or Managers, Bronchoscopy staff, Chaplains, Clerical staff, computer programmers, construction staff, Correctional officers, Craft or repair staff, Dental staff, Dietician or dietary staff, ED staff, Engineers, Food Service staff, Health aides, health and safety staff, housekeeping or custodial staff, Infection Control staff, ICU staff, Janitorial staff, Laboratory staff, Maintenance staff, Morgue staff, Nurses, Pathology laboratory staff, Patient transport staff (including EMS), Pediatric staff, Pharmacists, Phlebotomists, Physical and Occupational Therapists, Physicians (assistant, attending, fellow, resident, or intern), including Anesthesiologists, Pathologists, Psychiatrists, and Psychologists, Radiology staff, Respiratory Therapists, Social workers, Students (e.g., medical, nursing, technicians, and allied health), Technicians (e.g., health, laboratory, radiology, and animal), and Volunteers."

2. Failing to have a system in place to ensure that all staff members comply with educational trainings/inservices relating to the identification, reporting, and controlling of infections and communicable diseases that have been mandated and/or deemed necessary by the hospital's infection control department. Findings:

The hospital's infection control data was reviewed. This review revealed a hospital had 11 documented hospital acquired infections in January of 2011, 19 documented hospital acquired infections in February of 2011, 17 documented hospital acquired infections in March of 2011, and 5 documented hospital acquired infections in April of 2011.

S8 (Infection Control Coordinator) was interviewed on 5/10/11 at 10:00 a.m. S8 reviewed the medical record of Patient #5. S8 reported that the hospital has identified the need to increase the education and surveillance relating to the control of infections and communicable diseases. S8 reported that measures have been implemented to reduce the risk of cross contamination in an effort to reduce the spread of infections. S8 reported that the measures have included changing the disinfecting products used in the hospital and providing education relating to the disinfecting products; providing educational inservices/trainings relating to standard precautions, hand hygiene, and personal protective equipment; and enforcing the use of signage to ensure that staff are utilizing the appropriate precautions when providing patient care. When asked if there was a system in place to ensure that all staff members comply with educational trainings/inservices relating to the identification, reporting, and controlling of infections and communicable diseases that have been mandated and/or deemed necessary by the hospital's infection control department, S8 reported that there was not a current system in place to ensure that all staff members are compliant with educational trainings that have been mandated by the infection control department.