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Based on interview and documentation review the hospital failed to meet the Condition of Participation for Governing Body as evidenced by it's failure to have an effective Governing Body that was legally responsible for the conduct of the hospital and insured that the facility operated in accordance with the Medicare Conditions of Participation.

Findings included:


The hospital failed to ensure the Governing Body was involved with the appointment of the Chief Executive Officer (CEO) of the hospital.
Please refer to A-0057.

Based on record review and staff interview, the Governing Body was not involved with the appointment of the Chief Executive Officer (CEO) of the hospital.
Findings included:

On 8/15/23 at 8:30 A.M., during the entrance interview, survey staff were introduced to the recently hired CEO of the hospital. This individual was also identified as the CEO on the organizational chart provided to survey staff.

Review of the personnel file for the CEO contained evidence of his employment by the corporation that owned the hospital; however, there was no evidence that his appointment had been approved by the hospital's Governing Body.

Review of meeting minutes of the Governing Body from 12/2022 through 4/2022 ,showed no evidence that the Governing Body approved the appointment of the CEO.

During an interview on 8/16/23 at 2:15 P.M., the CEO said he came on board as a temporary CEO in February 2023 and became the permanent CEO in June 2023. The CEO said that he was hired by the Hospital's Corporate team and there was no appointment by the Governing Body. The CEO said he attended 2 Governing Body meetings (February 2023 and April 2023) and was not pleased with the structure. The CEO said the last Governing Body meeting was held in April 2023 and he canceled the remaining scheduled meetings (May 2023, June 2023, July 2023 and August 2023) until he could get a handle on what the expectations of the Governing Body are. He said the governing Body By-Laws have not been reviewed or updated for years and that needs to be done before he can have more meetings.

Based on records reviewed and interviews, the hospital failed for three of three patient grievances (Grievance #1, Grievance #2 and Grievance #3) filed to ensure in its resolution of grievances, to provide the patients with written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patients to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:

The Hospital Policy and Procedure, titled, Patients' Rights, (reviewed January 2023), referenced the Notice of Patient Rights which indicated the right to file a grievance concerning treatment at the Hospital, and would seek to resolve the grievance and provide a written response within seven days.

Review of the Patient Advocate's written statement, dated 06/30/23, indicated she met with the patient to discuss the incident (Grievance #1) that occurred on 6/28/23 on the unit. The Patient Advocate's written statement indicated a staff member put a hand over the patient's mouth to keep him/her from vomiting while collecting vital signs.

Review of the Patient Advocate's written statement, dated 07/03/23, indicated she met with the patient to discuss the incident (Grievance #2) that occurred on 07/03/23 on the unit. The Patient Advocate's written statement indicated another patient entering the patient's room twice during the night despite reporting the incident to a charge nurse.

Review of the Patient Advocate's written statement, dated 07/19/23, indicated she met with the patient to discuss to the incident (Grievance #3) that occurred during a prior stay on 04/14/23 on the unit. The Patient Advocate indicated it was alleged that a patient touched the patient inappropriately.

During an interview on 08/16/23 at 2:15 P.M. and on all subsequent interviews during survey, the Patient Advocate said if a complaint was not easily and immediately resolved, she would be notified of the complaint as a Grievance, would meet with the patient(s) and document a written statement. The Patient Advocate said all investigative material, including her written statement(s), were expected to be entered into the Hospital's program platform for review and resolution. The Patient Advocate said she did not know if a written notice of the Hospital's decision was provided to the patient(s) related to Grievance #1, Grievance #2 and Grievance #3.

During an interview on 08/17/23 at 10:10 A.M., the Director of Nurse (DON) said the Hospital's Patient Rights Policy and Procedure indicated a written response to a grievance would be provided within seven days to the patient. The DON said she thought the Hospital's Human Resource Legal Team provided the written response to the patient reporting a grievance, as required, that included the name of the Hospital contact person, the steps taken on behalf of the patients to investigate the grievance, the results of the grievance process, and the date of completion. The DON said she did not know if a written notice was provided to the patient(s) related to Grievance #1, Grievance #2 and Grievance #3.

During an interview on 08/17/23 at 11:05 A.M., the Chief Executive Officer said it was determined that the patient(s) related to Grievance #1, Grievance #2 and Grievance #3 were not provided with a written notice that included the name of the Hospital contact person, the steps taken on behalf of the patients to investigate the grievance, the results of the grievance process, and the date of completion.

Based on observation, interview and policy review, the hospital failed to ensure patient care was provided in a safe environment, with a working nurse call system, in the event of an emergency, on 1 of 3 nursing units, for 6 of 6 beds in use (206B, 206C, 207A, 207B, 207C, 208A) on the 2 west extension unit.
Findings include:

Review of the Hospital Nurse Call policy, undated, included the following:

* The hospital maintains a safe and secure environment of care in part through the use of a nurse call system.

On 8/15/23 at 10:00 A.M., the surveyor observed 6 beds in use on the 2 west extension unit. On the wall near each bed was a nurse call box. The box failed to have a call light cord with button, instead it had a plug covering where the cord would be attached.

On 8/17/23 at 8:40 A.M., the surveyor observed 6 beds in use on the 2 west extention unit. On the wall near each bed was a a nurse call box. The box failed to have a call light cord with button, instead had a plug covering where the cord would be attached.

On 8/17/23 from 8:35 A.M. and 8:45 A.M., the surveyor was able to speak with 4 patients in the 6 beds without call light buttons. 3 patients said they did not know what they would do if they needed help in an emergency. 1 patient said it isn't great but they would have to yell for help.

During an interview on 8/17/23 at 8:45 A.M., Certified Nursing Assistant # (Lillian) said there used to be call light cords before, but they took them out a while ago, she did not know why but it didn't matter because you couldn't hear them anyway. She said there are counselors scheduled on the west side and nursing staff from 2 east comes over to do 30 minute checks.

During an interview on 8/17/23 at 8:50 A.M., Counselor # (Natalie) said there are counselors scheduled on the west side from 7:00 A.M. to 9:30 P.M. There is no coverage from 9:30 P.M. to 7:00 A.M..

During an interview on 8/17/23 at 9:55 A.M., the Director of Nursing said that the call lights should be in place and operating.

On 8/17/23 at 2:30 P.M., the surveyor observed the 6 beds on 2 west now had call light cords. When the surveyor activated the system for bed 206C, the light outside the door and at the nurses station activated but the sound still did not work.

On 8/17/23 at 3:00 P.M., the Director of Nursing said that the call light system should have an audible sound and a staff member should be assigned to the west side at all times when counselors are not on duty.

Based on staff interviews, and review of Quality Assessment and Performance Improvement (QAPI) indicators and meeting minutes, the hospital failed to meet the Condition of Participation for Quality Assurance and Performance Improvement as evidenced by it's failure to ensure there was an effective, ongoing, hospital-wide, data-driven program to ensure the safety and well-being of the patients. Findings include:

The hospital failed to ensure staff 1.) Conducted Root Cause Analysis (RCA) for quality indicators that were reviewed in the QAPI meetings and 2.) reviewed Grievances and Infection Control practices within the QAPI meetings.
Please refer to A-0273.


The hospital failed to integrate the Infection Prevention program into the hospital wide QAPI process.

Please refer to A-0283.

Based on review of the hospital's QAPI (Quality Assessment Performance Improvement) program documentation and staff interview the hospital failed to ensure staff 1.) Conducted Root Cause Analysis (RCA) for quality indicators that were reviewed in the QAPI meetings and 2.) reviewed Grievances and Infection Control practices within the QAPI meetings. Findings include:

1. Review of the five most recent QAPI Meeting Minutes, dated 1/19/23, 3/16/23, 4/20/23, 5/20/23 and 7/20/23 indicated that the following quality areas were reviewed: Incident Reports, Fall Reports and Medication Errors.

Review of the Incident Report section for each month indicated the number of incidents only. There was no trending, analysis or development of an improvement plan if needed.

Review of the Fall Report section for each month indicated the number of falls, which unit the fall occurred on and on which shift they occurred. There was no analysis of the falls or development of an improvement plan if needed.

Review of the Medication Error section indicated the number of medication errors. There was no trending, analysis or development of an improvement plan if needed.

During an interview on 8/17/23 at 2:30 P.M., the Director of Nursing said that the QAPI Committee has not been completing an RCA for any of the indicators they are monitoring.

2. Review of the five most recent QAPI Meeting Minutes, dated 1/19/23, 3/16/23, 4/20/23, 5/20/23 and 7/20/23 indicated that there were no quality areas related to Infection Control or the Grievance process addressed at the QAPI meetings.

During an interview on 8/17/23 at 2:30 P.M., The Regional Quality Manager said that Infection Control should be part of the QAPI process and should be addressed at every QAPI meeting. He said that he could see that Infection Control had not been added to the hospital's QAPI indicators.

During an interview on 8/17/23 at 2:30 P.M., the Director of Admissions said that they do not discuss Grievances at the QAPI meetings.

Based on interviews and document reviews the hospital failed to integrate the Infection Prevention program into the hospital wide QAPI process.
Findings include:

Review of the Quality Assurance and Performance Improvement (QAPI) log indicated that meetings had occurred on 1/19/23, 4/20/23, 5/20/23,7/20/23 (the 2/2023 and the 6/2023 QAPI meetings were canceled). The log failed to include a signature to indicate attendance by the Infection Preventionist (IP).

The QAPI Meeting Minutes for 3/16/23 and 4/20/23 indicated a former IP was present at the QAPI meeting, but there were no documented discussions in regard to infection control practices or performance improvement projects by the hospital.

During an interview on 8/17/23 at 9:00 A.M., the Infection Preventionist (IP) and the Director of Nursing (DON) said the IP, who started her position in March 2023, was not a member of the QAPI committee, had not been invited to attend QAPI meetings, was unaware of the QAPI initiatives in the hospital and had not discussed or submitted any QAPI projects to the committee or participated in any QAPI discussions about infection control. The IP and DON said they had no knowledge of any active infection control performance improvement projects in the hospital.

Based on document review and interviews, the hospital failed to ensure that all licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital.

Findings include:

The policy titled Diversion Control Plan, last revised 02/2020, states under the section, Inventory Control, "Count of controlled substances is conducted by two nurses, outgoing and incoming medication nurses, at shift change per Hospital policy."

During an interview and observation on 8/16/23 at 9:40 A.M., Registered Nurse (RN) #3 demonstrated how nurses conduct inventory of the controlled substances medications on the medical unit (3 East). Medications are stored in an automated dispensing cabinet (ADC). RN #3 showed the surveyor that this ADC had three categories regarding inventory of controlled substances, a) Accessed controlled substances, b) All controlled substances, c) Non-accessed controlled substances. RN #3 said that the nurses will only count the "accessed controlled substances" category during each shift change.

During an interview on 8/16/23 at 12:05 P.M. RN #4 also said that only "accessed controlled substances" are counted every shift change.

During an interview on 8/16/23 at 2:30 P.M. RN #5 and RN #6 said that prior to ADC installation the practice was to count all controlled substances during each shift change. However, since an ADC was installed in the medication room, the current practice is for only "accessed controlled substances" to be counted during each shift change.

The policy titled Diversion Control Plan, last revised 02/2020, states under the section, Nursing Unit Security, "Controlled substances on nursing units are secured according to Federal and State laws. The controlled substances cabinet is locked within the locked medication room, ensuring a double-locked environment. The responsible medication nurse controls entry to both."

During an observation on 8/16/23 at 9:40 A.M. and 12:05 P.M., the 2nd and 3rd floor medication rooms did not have a lock on their respective refrigerators, failing to maintain a double lock environment. The medication refrigerators contain the controlled substance lorazepam.

Based on observation, policy review and interview, the hospital failed to ensure 1 of 4 staff (Licensed Practical Nurse (LPN) #2 ) observed, prepared and administered medications that had been properly identified per the facility policy.

Findings include:

Review of the hospital policy titled Administration, Verification and Storage of Patient's own Medications (dated as reviewed 1/2019) indicated but was not limited to the following:

-Patient's own medications are not used routinely. However, when such medications are not readily available and the patient's condition requires that the patient receive the medication, the patient's own medication may be administered with an order from the Medical Doctor (MD)/ Nurse Practitioner (NP).

-These drugs shall not be administered unless they can be identified. The Pharmacy Department shall verify patient's own medications. In the event the pharmacy is closed, a licensed nurse, in consultation with a physician, shall identify the patient's own medication.

-The pharmacist will place a green sticker near the label with the date and his/her initials which indicates verification.

-If the patient's own medications are not to be used, they are to be bagged and labeled with the patient's name and stored in a patient medication area located in each medication room.

During an observation on 8/17/23 at 8:25 A.M., LPN # 2 was in the process of pouring medications to be administered to a patient. LPN #2 was removing the medications from the Automated Dispensing Cabinet (ADC). LPN #2 then opened the cabinet located within the medication room and obtained a large plastic bag containing bottles of medications (the plastic bag was labeled with a patient's name). LPN #2 opened the patient specific plastic bag and obtained a bottle of pills from the bag. LPN #2 then poured one of the pills into the cap of the medication bottle, and then poured the pill into the medication cup, which contained the patient's medications that had been dispensed from the ADC. LPN #2 then administered the medications to the patient.

During an interview on 8/17/23 at 8:30 A.M., the surveyor asked LPN # 2 what medication was removed from the patient's home medications. LPN # 2 said that the medication was Glipizide (anti-diabetic agent). LPN #2 said that the Glipizide was not in the ADC. He further said he does not access and dispense a medication from the patient's home medications often, but the ADC did not have the Glipizide.

During an interview on 8/17/23 at 11:40 A.M., Registered Nurse (RN) #2 said that if a medication brought in by the patient is dispensed from these medications, the physician's order must specifically indicate that the patient's medications from home are approved for use and the order would indicate *Pt home med*.

RN #2 said that if the physician's order does not indicate to use the patient's medications, then he would not use any of the medications brought in (would not obtain medications from the plastic bags stored in the medication room). RN #2 said that if the medication was not in the ADC (out of stock) and the patient did not have a physician's order to use the home medications, he would call down to the Pharmacy (located in the hospital) and see if the medication could be obtained.

Review of the physician's order for the Glipizide was as follows:

Glipizide XL (extended-release tablet) 10 milligrams (mg) every day. The order did not indicate *Pt home med*

During an observation on 8/17/23 at 12:30 P.M., the bottle of the patient's Glipizide was noted not to have a green sticker or any initials or date that the medication had been verified.

During an interview on 8/17/23 at 1:00 P.M., the Director of Nursing (DON) said no medications should be removed from the plastic bag of the patient's home medications for use. She further said that all the medications should be supplied/dispensed through the ADC. In an instance where the pharmacy would not normally have on hand or stock the medication, then the patient's medications brought in by the patient can be used. The physician's order would then indicate *Pt home med*. The DON said that aside from the above instance, all medications should be dispensed using the ADC.

The hospital pharmacy department failed to maintain current and accurate records regarding receipt and disposition of all scheduled drugs.

Findings include:

The policy titled Diversion Control Plan, last revised 02/2020, states under the section, Inventory Control, "A weekly and biennial inventory of controlled substances is conducted by the Chief Pharmacist or his/her designated pharmacist according to Federal and State Laws."

The surveyor reviewed the controlled substances inventory logbook on 8/17/23 at 12:20 P.M. For the drug Adderall 10 milligram (mg), the most recent inventory and/or adjustment made was on 5/10/23. There were no documented inventory checks nor any type of documentation for Adderall 10 mg since 5/10/23.

During an interview on 8/17/2023 at 12:20 P.M., the pharmacy director said that a full inventory of controlled substances is done every seven days. The pharmacy director acknowledged that the controlled substances inventory logbook for Adderall 10 mg did not have any further documentation regarding inventory checks since 5/10/23.

Based on observations, record review and interviews, the hospital failed to meet the Condition of Participation for Physical Environment. It was determined the hospital failed to ensure 1.) It met the requirements for fire safety in accordance with Chapter 19 of the National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 Edition related to Life Safety from Fire and Maintenance of the Physical Plant 2.) Windows in patient rooms were properly sealed and 3.) Staff maintained equipment at an acceptable level of safety and quality.
Findings include:

1. Please refer to Life Safety Code survey findings for survey date ending 8/16/23 (Event ID 088W21).

2. The hospital failed to maintain the physical environment in working condition on 1 of 3 patient units (second floor).

Please refer to A-0701.

3. The hospital failed to ensure its staff maintained equipment at an acceptable level of safety and quality as follows: 1) Ensure dietary staff maintained kitchen equipment to an acceptable level of safety and sanitation; and 2) Ensure nursing staff conducted Code Cart checks per the facility policy, and failed to ensure expired solutions and medications were removed once expired.

Please refer to A-0724.

Based on interview and observation, the hospital failed to maintain the physical environment in working condition on 1 of 3 patient units (second floor).

Findings include:

On 8/17/23 at 8:45 A.M., the surveyor observed on the second floor patient unit bedrooms and activity room, slider windows with moisture and mildew built up between the panes. Approximately 80% of the window areas were clouded and opaque due to the mildew and precipitation and prevented patients from having a clear view of the outdoors or receiving unobstructed sunlight.

Rooms affected included:

* Room 206 (both windows)
* Room 207 (two of three windows)
* Room 208 (two of three windows)
* Activity rooms 216 and 217 (three of six windows)

During an observation and interview with the Facilities Director on 8/17/23 at 1:45 P.M. on the second floor, the surveyor and Facilities Director entered rooms 206, 207, 208, 216 and 219. The Facilities Director said the rubber seal on the bedroom sliding windows had worn down and allowed moisture to enter between the panes and causing mildew to grow. The Facilities Director said he was unaware of the condition of these windows.

Based on observation, document review and interview, the Hospital failed to ensure its staff maintained equipment at an acceptable level of safety and quality. Specifically the Hospital failed to:
1) Ensure dietary staff maintained kitchen equipment to an acceptable level of safety and sanitation; and
2) Ensure nursing staff conducted Code Cart checks per the facility policy, and failed to ensure expired solutions and medications were removed once expired.

Findings include:

1. Review of the Dietary Department's Policies and Procedures, dated 9/16/15, indicated the following:
*The Food Service Manager is responsible for supervising all sanitation and housekeeping procedures used in the kitchen.
*Equipment, work surfaces, walls and floors are maintained in sanitary condition by daily, ongoing procedures.
*The food service department is cleaned on a regular basis utilizing a system that covers all equipment.

During an initial tour of the kitchen on 8/15/23 at 9:15 A.M., the following concerns were observed:
-The meat slicer had dried food debris around the blade and cover.
-The handles of two ovens were greasy to the touch.
-A large wall mounted fan's blades and cover had a build up of dirt, grease, and grime. The fan was turned on and pointed directly at the meal preparation and service area.
-A large overhead exhaust fan's exterior grate (covering) was dirty with debris. The exhaust fan was in use and was mounted directly above stacks of clean plate covers and heated pellets, used to keep the plates warm during meal service.
-Several sheet pans and 15 steam table pans were stacked together and when separated had water dripping from the pans.
-A soup kettle was very dirty with dried on debris along the outside edges and on the steam connection that it was attached to.
-The area underneath the large skillet was dirty with a buildup of thick solidified grease.
-The walk-in Freezer (referred to as the cook's freezer) had temperature readings of 20 degrees Fahrenheit (F) on the external and internal thermometers, (normal range 10 to -10 degrees F).
-The inside gasket and interior fixtures of the ice machine were dirty and stained. The gasket was laden with a black substance.
-A large fan in the dishroom had dirty fan blades and dirt hanging off its outer cover. The fan was on and in use. The power cord for the fan was loosely draped over pipes.

During a second tour of the kitchen on 8/16/23 between 9:00 A.M. through 10:15 A.M., the following concerns were observed:
-The large fan in the dishroom remained dirty and in use.
-The exhaust fan remained dirty and in use.
-The soup kettle outer fixtures remained greasy and dirty. At this time, Cook #1 said the soup kettle was being used because the steamer was broken.

During a third tour of the kitchen on 8/17/23 at 7:55 A.M., the following concerns were observed:
-The large fan in the dishroom remained dirty and in use. Additionally, a small fan was mounted on the ceiling that was covered in dirt. The Food Service Director (FSD) said it was not being used.
-There were areas of chipped paint on the radiator behind shelving in the dishroom. Also, there were areas of chipped paint on the ceiling in the dishroom.
-The exhaust fan remained dirty and in use.
-The soup kettle outer fixtures remained greasy and dirty.
-A large walk-in freezer (referred to as the baker's freezer) had temperature reading of 28 degrees F on the external thermometer. The door gasket was dirty, broken, and there were several areas of ice build-up on the door edges, the ceiling, and the floor. The pipe along the outside edge of this freezer had areas of ripped foam pipe covering, in addition to a large, dirty, and wet towel wrapped around an area of the piping.

During an interview on 8/17/23 at 8:15 A.M., the FSD said they do not have a master cleaning schedule due to a shortage of staff, rather the FSD said that she and the supervisor make a weekly list of equipment to clean as needed.


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2. The facility failed to ensure that Code Cart checks were conducted per the facility policy, and failed to ensure expired solutions and medications were removed once expired.

Review of the hospital policy, entitled, Code Cart Checks, last reviewed March 2023, included the following:

* Code Cart checks will be done by licensed staff and will include inspection of all drawers, ambu bags, medications, and suction. Any expired medications or supplies/items will be replaced at this time.
* Code Carts will be checked weekly on each unit.
* Replacement supplies and medications will be obtained from the Nursing Supervisor
after each use, and as needed.
* Each shift will share responsibility for the Code Cart checks on a rotating basis. The
schedule is posted on each unit.
* The Code Carts kept in the basement and first floor will be checked monthly by a Nursing Supervisor.

Records are maintained on each unit and reported to the Quality Improvement Committee on a monthly basis.

Review of the hospital policy, entitled, Emergency Medical Equipment, last reviewed March 2023, included the following:

* It is the policy of the hospital to respond to possible medical emergencies by placing equipment and supplies strategically throughout the hospital as follows:
A "Code Blue" Crash Cart is located in the Admitting Office, Basement, 2 East Unit, 2 West Unit, 3 East Unit, 4 East Unit.

* Crash Cart Contents: Each cart has an attached stock level list of all equipment listed by drawer and location in the cart.

* Equipment Check: Carts are kept locked for several reasons, particularly because of the contents and the patient population. Nursing is responsible to monitor all medications and I.V.s within the cart and note expiration dates on the contents' checklist.

* Nursing is responsible to assure all listed equipment is on or with the cart weekly.

A. On 8/15/23 at 10:30 A.M., a tour of the 2 West unit, revealed a Code Cart located across from the nurses' station. Review of the Code Cart Checklist indicated that the Nurse should Check the Code Cart Contents Checklist for expiration dates, and if an item is expired, the nurse will replace it and complete a new checklist. Review of the Checklist listed weekly dates from 3/29/23 through 8/9/23 for a total of 20 weeks. 17 of 20 dates were left blank.

Review of the Crash Cart Contents checklist, dated 4/6/23, indicated two 1000 milliliter bags of intravenous dextrose and saline solution, with expiration dates of 7/2023, one bottle of aspirin 325 milligrams tablets, with an expiration date of 6/2023 and intravenous dextrose 50% injection, with an expiration date of 5/2023.

During an interview on 8/15/23 at 10:45 A.M., Registered Nurse (RN) #7 said that the 2 West Code Checklist was incomplete and it should be checked weekly by the nurse. RN #7 said that when medications in the code cart are expired the nurse should replace them and update or change the Crash Cart Contents checklist. RN #7 said the 2 West checklist was not updated to show that the expired medications were replaced.

During an observation on 8/17/23 at 10:30 A.M., on the 2 West Unit, the Assistant Director of Nursing(ADON) opened the Code Cart and which revealed the two 1000 milliliter bags of intravenous dextrose and saline solution, with expiration dates of 7/2023, one bottle of aspirin 325 milligrams tablets, with an expiration date of 6/2023 and intravenous dextrose 50% injection, with an expiration date of 5/2023.

During an interview on 8/17/23 at 10:40 A.M., the ADON said that when the Crash Cart Contents checklist indicated there were expired medications, the staff should have removed the expired medications from the cart and they should have completed another Crash Cart Contents Checklist.


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B. On 8/17/23 at 8:15 A.M., a tour of the 4 East Unit, revealed a code cart located at the nurse's station. Review of the Code Cart Checklist indicated that the Nurse should check the Code Cart Checklist for expiration dates, and if item is expired, the Nurse should replace item and complete a new checklist. Further review of the Checklist indicated staff checking the Checklist should ensure there is a red safety tab intact on the code cart.

Review of the Checklist listed weekly dates from 3/29/23 through 8/9/23 for a total of 20 weeks. 12 of the 20 dates were left blank.

Observation of the Code Cart indicated there was no red safety tab intact on the Code Cart.

During an interview on 8/17/23 at 8:25 A.M., Registered Nurse #2 said he was not sure why the code cart was not checked, but that it is supposed to be checked every Wednesday. He also said he was unsure why a red tab was not attached to the cart and that he would have to get a new one.

Based on observation, record review and interviews, the hospital failed to meet the Condition of Participation for Infection Control, as evidenced by the hospital's failure to implement an appropriate and effective Infection Control Program for the prevention, control, and investigation of infections and communicable diseases.

Findings include:

1. The hospital failed to ensure the Governing Body appointed the Infection Preventionist (IP) to her position and failed to ensure the Infection Preventionist was qualified for the position.

Please refer to A-0748.

2. The hospital failed to ensure its staff employed effective methods for preventing and controlling the transmission of infections within the hospital.
Specifically:
a) Staff failed to screen for Coronavirus (COVID-19) infection upon admission for one Patient (#7), out a total sample of 30 patients.
b) Staff failed to do annual Tuberculosis screening for four of 14 sampled employees, and failed to obtain required medical information and vaccination status for one of 14 sampled employees.
c) Dietary staff failed to a) maintain appropriate hand hygiene practices, b) failed to prevent potential cross contamination during meal tray service, and c) failed to wear appropriate facial hair restraints in food service areas.
d) Staff failed to ensure that Registered Nurse #5 adhered to infection control practices to minimize the risk of spread of infection during administration of medications on one of three nursing units.
e) Staff failed to clean vital sign monitors before or after each patient use.

Please refer to A-0749

3. The hospital failed to ensure the Governing Body appointed a leader of the antibiotic stewardship program and the Infection Preventionist, who managed the program, was qualified for the position.

Please refer to A-0760.

4. The hospital's Governing Body failed to ensure the antibiotic stewardship program was addressed and incorporated into its Quality Assurance and Performance Improvement (QAPI) program.

Please refer to A-0761.

5. The hospital failed to ensure it utilized national guidelines to manage the use of antimicrobial agents.

Please refer to A-0764.

6. The hospital's Governing Body failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee addressed infectious diseases and use of antibiotics that were identified through the infection control program.

Please refer to A-0771.

7. The hospital failed to ensure the Infection Preventionist, other qualified professional, or an online educational program, educated or trained staff in infection control and prevention control practices.

Please refer to A-0775.

Based on record review and interview, the hospital failed to ensure (1) the Governing Body appointed the Infection Preventionist (IP) to her position and (2) the Infection Preventionist was qualified for the position.

Findings include:

1. The hospital failed to ensure the Governing Body appointed the Infection Preventionist.

Review of the Governing Body Bylaws, last reviewed December 2017, failed to indicate the requirement to appoint a hospital Infection Preventionist.

Review of the Governing Body minutes dated March 2023, indicated there was no reference to the appointment of the IP or reference to recommendations of medical staff leadership and nursing leadership for the appointment.

During an interview on 8/17/23 at 9:00 A.M., the Director of Nursing (DON) and Infection Preventionist (IP) said Governing Body had not appointed the IP to the position, which she began in March 2023. The IP and DON said they were unaware the Governing Body was required to appoint the IP or of the requirement for the appointment to be based on the recommendations of medical staff leadership and nursing leadership.

2. The hospital failed to ensure the Infection Preventionist was qualified for the position.

Review of the Infection Preventionist's (IP) personnel and training documents indicated there was no education, training, certification, or previous work experience in infection prevention and control.

During an interview on 8/17/23 at 9:00 A.M., the IP and Director of Nursing (DON) said the IP began her position in March 2023, and did not have education, training, certification, or previous work experience in infection control or as an IP. The IP said she had worked as a direct care nurse for approximately 40 years until March 2023 when a human resources representative offered her the position of part-time IP and part-time scheduler. The IP said she was not trained for the position and was learning "on the job".

Based on record review, observation, interview, and policy review, the hospital failed to ensure its staff employed effective methods for preventing and controlling the transmission of infections within the hospital.
Specifically:
1) Staff failed to screen for Coronavirus (COVID-19) infection upon admission for one Patient (#7), out a total sample of 30 patients.
2) Staff failed to do annual Tuberculosis screening for four of 14 sampled employees, and failed to obtain required medical information and vaccination status for one of 14 sampled employees.
3) Dietary staff failed to a) maintain appropriate hand hygiene practices, b) failed to prevent potential cross contamination during meal tray service, and c) failed to wear appropriate facial hair restraints in food service areas.
4) Staff failed to ensure that Registered Nurse (RN) #5 adhered to infection control practices to minimize the risk of spread of infection during administration of medications on one of three nursing units.
5) Staff failed to clean vital sign monitors before or after each patient use.

Findings include:

1. The hospital failed to screen for Coronavirus (COVID-19) infection upon admission for Patient (#7).

Review of the hospital's Infection Control COVID-19 policy, dated February 2021, indicated the following:
-All persons presenting for admission will be tested using both rapid-result testing and polymerase chain reaction (PCR) testing methods. Patients will remain in the designated isolation area until a negative result via the rapid method is attained.

Patient #7 was admitted to the facility in July 2023 with a diagnosis of Substance Use Disorder.

Review of a Physician's order, dated 7/31/23, indicated COVID-19 Binax (brand of rapid testing) times one. Further review of the clinical record indicated this order was canceled, and reordered again on 8/3/23 (four days later), at which time the test was done.

During an interview on 8/16/23 at 1:50 P.M., the Director of Nurses (DON) said all patients being admitted to the hospital are administered a rapid COVID-19 test as part of the admission process. She said, after reviewing the clinical record for Patient #7, there was no documented evidence why the rapid COVID-19 test had not been administered as ordered during the Patient #7's admission process on 7/31/23.

2. The hospital failed to obtain annual Tuberculosis screening for four of 14 sampled employees, and failed to obtain required medical information and vaccination status for one of 14 sampled employees.

Review of the hospital's Employee Health Program policy, dated 2022, indicated the following:
-The hospital seeks to protect its personnel's health by the completion of a pre-employment physical questionnaire and testing per the Occupational Safety and Health Administration (OSHA) Regulations as evidenced in the infection control manual.
-A pre-placement, post-offer physical questionnaire will be completed by the employee at the time of hire. The Medical Director or designee will be review and sign off on questionnaires when new hire requests accommodation or when drug testing is returned with positive results for a controlled substance. Employment is contingent upon passing the physical in accordance with the American with Disabilities guidelines.
-A Hepatitis B Vaccine with be offered to all "high risk" personnel within ten days of their employment. If an employee does not want to receive the vaccination, a declination form will be signed.
-A Tuberculin Skin Test (TST) or T-Spot test will be given to all new employees and interns before they begin work if they have not been tested within the previous 90 days. Employees will be re-tested within 30 to 40 days of hire and will answer a screening test on an annual basis. The annual screening test will be reviewed by Nursing.
-All new hires are expected to provide evidence of Measles/Mumps/Rubella (MMR) vaccine/titers and COVID vaccine status or apply for medical/religious exemptions at the time of hire.

Review of employee files indicated the following:
a) The Food Service Director was hired 11/10/17. Review of her employee record indicated her last Employee TB and History Assessment was completed 7/8/22.

b) The Dietary Supervisor was hired 5/26/92. Review of her employee record indicated her last Employee TB and History Assessment was completed 6/13/22.

c) Cook #2 was hired 9/2/20. Review of his employee record indicated his last Employee TB and History Assessment was completed 6/28/22.

d) The Placement Specialist was hired 12/2/21. Review of his employee record indicated his last Employee TB Assessment was completed on 6/24/22.

During an interview on 8/17/23 at 2:30 P.M., the DON said that the Employee TB and History Assessments had not been completed for any employee during 2023

e) The Chief Executive Director (CEO) was hired 4/17/23. Review of his employee record indicated no medical information.

During an interview on 8/17/23 at 11:45 A.M., the CEO said he was unsure if the Hospital had the required medical documentation needed before he started his position.

As of 8/17/23 at 4:15 P.M., at the conclusion of the survey, the CEO's required medical documentation had not been provided to the surveyor.

3. The hospital failed to ensure dietary staff a) maintained appropriate hand hygiene practices, b) prevented potential cross contamination during meal tray service, and c) wore appropriate facial hair restraints in food service areas.

Review of the Dietary Personnel and Infection Control policy, dated 9/15/13, indicated the following:
-The Food Service Manager is responsible for supervising all sanitation and housekeeping procedures used in the kitchen.
-Hair must be contained. All personnel are required to wear hats, hairnets, or surgical caps.
-Handwashing: Thorough handwashing is done by all employees after handling patient care items or equipment, and anytime microbial contamination of the hands is likely or suspected.

Review of the 2022 FDA Food Code indicated:
2-402 Hair Restraints
2-402.11 Effectiveness.
(A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles.

a) During an observation of lunch meal service on 8/15/23 between 12:05 P.M. and 12:31 P.M., on two of three units, the following infection control concerns were observed:

The Four East meal truck was brought to the unit by Dietary Staff #1 at approximately 12:05 P.M. He donned gloves before beginning the process of passing meal trays to patients in their rooms. He was observed wearing the same pair of gloves while passing meal trays to all patients on the unit.

He was observed knocking on bedroom doors, opening, and closing doors, as well as moving personal items on several patient's bedside tables before leaving meal trays in the patient's rooms. He was observed removing paper meal tickets from each patient's meal trays and placing them on top of the meal truck. At this time, he said the same paper meal tickets were used for all three meals each day.

During the meal tray pass, he did not doff his dirty gloves and/or perform hand hygiene between patient rooms.

The Three East meal truck was brought to the unit by Dietary Staff #2 at approximately 12:18 P.M. He obtained disposable gloves from a dispenser on the wall, dropped them on the floor and then donned the gloves before beginning the process of passing meal trays to patients in their rooms. He was observed wearing the same pair of gloves while passing meal trays to all the patients on the unit.

He was observed knocking on bedroom doors, opening, and closing several doors. He was observed removing the paper meal tray tickets from each patient's trays and placing them on top of the meal truck to be reused for the supper meal that day.

During the meal tray pass, he did not doff his dirty gloves and/or perform hand hygiene between patient rooms.

b) During an interview on 8/16/23 at 10:15 A.M., Cook #1 was observed scratching his face and under his work shirt with his bare hand and then returning to food preparation. He did not wash his hands before returning to food preparation.

c) During several tours of the kitchen and meal tray passes on 8/15/23, 8/16/23 and 8/17/23, the following were observed;
-Cook #1 had a ponytail of unrestrained hair hanging out from the back of his chef hat. He was also observed to have a full beard and mustache that was not covered with an appropriate hair restraint. He was wearing a surgical face mask that did not cover all his facial hair.
-Dietary Staff #1 was observed to have a full beard and mustache that was not covered with an appropriate hair restraint. At times he was observed wearing a surgical mask that did not cover all his facial hair and at times he had no mask on while walking throughout the kitchen and dishroom.

During an interview on 8/17/23 at 8:15 A.M., the Food Service Director(FSD) said that staff should not don gloves that were dropped on the floor. She said staff should be washing their hands after touching any body parts and before moving onto food preparation. She also said that she had not considered the infection control concern posed by re-using meal tray tickets after Dietary Staff were handling them with dirty gloves. The FSD said that appropriate facial hair restraints were not being used, but should have been.


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4. The hospital failed to ensure that Registered Nurse (RN) #5 adhered to infection control practices related to hand hygiene to minimize the risk of spread of infection during administration of medications on one of three nursing units during administration of medication.

Review of the Hospital Hand Hygiene Program, reviewed 3/2023, included the following indications for performing hand hygiene:
* Before, between, and after all physical contact with the patient.
* Before preparing or serving food or administering medications.

Review of the hospital Hand Hygiene Surveillance tool, undated, included that hand hygiene should be performed:
* Prior to patient contact
* After patient contact
* After passing meds

On 8/15/23 at 9:48 A.M., the surveyor observed RN #5 prepare medications for a patient. While attempting to remove a medication from a bubble pack she used her fingernail to poke a hole in the seal, contaminating the medication. She placed the medication in a cup and administered it to the patient. After administering the patient's medications she failed to perform hand hygiene.

On 8/15/23 at 9:53 A.M., without performing hand hygiene, RN #5 proceeded to place her hand on the next patient's arm to access his/her identification band. While preparing this patient's medications, one of the pills dropped onto the table, contaminating the medication. She picked up the medication and administered it to the patient. After administering the patient's medications she failed to perform hand hygiene.

On 8/15/23 at 10:02 A.M., without performing hand hygiene, RN #5 proceeded to place her hand on the next patient's arm to access his/her identification band. After administration, she failed to perform hand hygiene.

On 8/15/23 at 10:22 A.M., without performing hand hygiene, RN#5 proceeded to place her hand on the next patient's arm to access his/her identification band. While attempting to remove medications from bubble packs she used her fingernail and pen to poke a hole in the seal, contaminating the medication.

During an interview on 8/15/23 at 1:17 P.M., RN #5 said that she should have performed hand hygiene between each patient, she should not have administered the medication that had fallen on the table and she should not have used her pen or fingernail to open the bubble packs of medications.

During an interview on 8/15/23 at 3:57 P.M., the Director of Nurses said that hand hygiene should be performed between each patient during medication administration, medication that falls should not be used and fingernails and pens should not be used to open bubble packs.


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5. The hospital failed to ensure Treatment Assistant #1 disinfected vital sign equipment between patient use.

Review of the hospital policy, titled, Cleaning and Disinfecting of Equipment, dated 3/23, indicated blood pressure cuff and tubing would be wiped down with alcohol prep pad prior to use, and between each patient, and the person who used the equipment was responsible for cleaning it.

During observation on the third floor on 8/17/23 at 9:36 A.M., the surveyor observed Treatment Assistant (TA) #1 using the unit's vital sign machine to measure vital signs on a patient in front of the nurses' station. The vital signs included blood pressure and temperature check. TA #1 returned the blood pressure cuff and thermometer to it's holder on the machine, but did not clean the blood pressure cuff in any way, did not wipe the thermometer probe and did not clean the vital sign machine in any way. TA #1 then rolled up the blood pressure cuff and returned it to the basket attached to the vital sign monitor cart. TA #1 then went behind the nurses' station and began documentation.

During an interview on 8/17/23 at 9:39 A.M., TA #1 said one of her duties was to help collect vital signs on patients in the morning and sometimes at the request of the nurse. TA #1 said she did not clean the vital sign monitor, blood pressure cuff, or thermometer probe between use for each patient. TA #1 said she intended to wipe these down after collecting the vitals for the whole unit.

During an interview on 08/17/23 at 10:12 A.M., The Director of Nurses said vital sign machines and any patient equipment should be wiped down between each patient, as per hospital policy.





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Based on record review and interview, the hospital failed to ensure (1) the Governing Body appointed a leader of the antibiotic stewardship program and (2) the Infection Preventionist, who managed the program, was qualified for the position.

Findings include:

1. Review of the Governing Body Bylaws, last reviewed December 2017, failed to indicate the requirement to appoint a leader of the hospital's antibiotic stewardship program.

Review of the Governing Body minutes dated March 2023, indicated there was no reference to the appointment of the Infection Preventionist (IP), or reference to recommendations of medical staff leadership and pharmacy leadership for a leader of the antibiotic stewardship program.

During an interview with the Infection Preventionist (IP) and the Director of Nursing (DON) on 8/17/23 at 9:00 A.M., they said the Governing Body had never communicated that she was appointed leader of the antibiotic stewardship program, which role she began in March 2023. The IP and DON said members or representatives of the Governing Body had never been in communication with either the IP or DON about a Governing Body appointment. The IP and DON said they were unaware the Governing Body was required to appoint a leader of the antibiotic stewardship program or that the appointment is based on the recommendations of medical staff leadership and pharmacy leadership.

2. Review of the Infection Preventionist's (IP) personnel and training documents indicated there was no education, training, or previous work experience in antibiotic stewardship.

During an interview with the IP and Director of Nursing (DON) on 8/17/23 at 9:00 A.M., they said the IP began her position in March 2023, and did not have education, training, or previous work experience in antibiotic stewardship. The IP said she had worked as a direct care nurse for approximately 40 years until March 2023 when a human resources representative offered her the position of part-time IP and part-time scheduler. The IP said she was not trained for the position and was learning "on the job".

Based on record review and interview, the hospital Governing Body failed to ensure the antibiotic stewardship program was addressed and incorporated into the Quality Assurance and Performance Improvement (QAPI) program.

Findings include:

1. Review of the Governing Body minutes dated March 2023, indicated there was no reference to the antibiotic stewardship program or that the program was addressed in the hospital QAPI program.

Review of the five most recent QAPI Meeting Minutes, dated 1/19/23, 3/16/23, 4/20/23, 5/20/23 and 7/20/23, failed to include any reference to the hospital's antibiotic stewardship program, or that the Infection Preventionist (IP), or other staff responsible for the antibiotic stewardship program, attended the monthly meetings. The QAPI minutes also failed to include the prevalence of infectious diseases in the hospital or the use of antibiotics.

During an interview on 8/17/23 at 900 A.M., the IP and the Director of Nursing (DON) said the IP began her position in March 2023, and she was responsible for the hospital's antibiotic stewardship program. The IP said she had not attended, or been invited to attend, a QAPI meeting to share information about the antibiotic stewardship program. The IP and DON said the IP had not submitted patient reports for infectious diseases, or the use of antibiotics, to the QAPI committee. The IP and DON said the infectious disease and antibiotic use logs for May 2023, June 2023 and July 2023 were shared monthly at the medical executive meeting, but were not presented or addressed in QAPI meetings or QAPI program. The IP and DON said the hospital's antibiotic stewardship program was not addressed in the QAPI process.

Based on policy review and interview, the hospital failed to ensure it utilized national guidelines to manage the use of antimicrobial agents.

Findings include:

Review of the hospital's policy, titled, "Antibiotic Stewardship" last reviewed and revised in March 2023, indicated:

* The hospital shall utilize standard procedures, evidence-based national guidelines, and recognized best practices/risk reduction strategies to manage the use of antimicrobials.

During an interview on 8/17/23 at 9:00 A.M., the Infection Preventionist (IP) and the Director of Nursing (DON) said they were unaware the hospital was required to follow national guidelines for the use of antimicrobials. The IP and DON said they were not familiar with antimicrobial guidelines, such as those recommended by the Centers for Disease Control, or the McGeer criteria.

The McGeer criteria is a set of guidelines used to define infections in healthcare settings.

Based on record review and interview, the hospital Governing Body failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee addressed infectious diseases and use of antibiotics that were identified through the infection control program.

Findings include:

Review of the Governing Body Bylaws, last reviewed December 2017, indicated that a Performance Improvement Committee has primary responsibility for the implementation of the Performance Improvement Plan. The committee will develop a system-wide plan and submit to the Governing Body for approval.

Review of the Quality Assurance and Performance Improvement (QAPI) log indicated that meetings had occurred on 1/19/23, 4/20/23, 5/20/23,7/20/23 (the 2/2023 and the 6/2023 QAPI meetings were canceled). The log failed to include a signature to indicate attendance by the Infection Preventionist (IP).

The QAPI Meeting Minutes for 3/16/23 and 4/20/23 indicated a former IP was present at the QAPI meeting, but there were no documented discussions in regard to infection control practices, including antibiotic stewardship, for performance improvement projects by the hospital.

The minutes also failed to reference the prevalence of infectious diseases in the hospital or the use of antibiotics. There was no reference to addressing or integrating the infection control program into QAPI.

During an interview on 8/17/23 at 9:00 A.M., the Infection Preventionist (IP) and the Director of Nursing (DON) said the IP began her position in March 2023, and had not attended, or been invited to attend, a QAPI meeting to share information about the hospital's infection control program. The IP and DON said the IP had not submitted patient reports for infectious diseases or the use of antibiotics to the QAPI committee. The IP and DON said the hospital's infection control program was not a participant in the QAPI process.

The IP, DON and surveyors reviewed infectious disease and antibiotic use logs for May 2023, June 2023 and July 2023. The IP and DON said these logs were shared monthly at the medical executive meeting, but were not presented or addressed in QAPI meetings.

Based on record review and interview, the hospital failed to ensure the Infection Preventionist, other qualified professional, or an online educational program, provided education and training to staff relative to infection prevention and control practices.

Findings include:

During an interview on 8/17/23 at 9:00 A.M., the Infection Preventionist (IP) and the Director of Nursing (DON) said they were unaware of any formal education or training in infection control and prevention provided to staff over the past 12 months. The IP and DON said the hospital used an online software program for its infection control and prevention competency and education. The surveyor requested a paper copy of all staff education and training for the past 12 months, which included new hires and existing staff. In addition, the DON provided the syllabus and content titled "Infection control and prevention basics, non-clinical", dated 2022.

Review of the staff listing for the hospital's online training and education dated 8/13/23, indicated that of the 106 staff included in the listing none of them had documentation to indicate they had completed an infection control and prevention course.