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Based on policy review, record review, and interview, the hospital failed to ensure patient rights were promoted by failing to provide care in a safe setting for three of four patients (Patient 1, 3, and 4) reviewed, who had falls and failed to ensure patients were free from neglect for one of 12 sampled patient care plans (Patient 1).

The cumulative effects of this deficient practices had the potential place the 37 current patients and any future patients admitted to the hospital at risk for greater injury and harm from falls.

Findings Include:

1. The hospital failed to ensure patients received care in a safe setting. Three (Patient 1, Patient 3, Patient 4) of four patient records reviewed for falls, had no documented evidence the bed was in a low position, and floor mats were in place next to the bed, as stated in the physician orders, and/or patient care plan to prevent injury from falls, and/or no documented evidence the bed/chair alarms were checked to assure proper function, and beds were in the low position. The hospital had 90 patient falls in four months (June, July, August, and September 2020). (refer to tag A0144)

2. The hospital failed to ensure a patient was free from neglect as evidenced by failure to have the bed of a patient on fall precautions in the lowest position, and by not having a mat on the floor next to the patient's bed as ordered by the physician, and/or included as interventions on the patient's care plan for one (Patient 1) patient falls reviewed from a sample of 12 patients. Patient 1 had a fall on 07/01/20 that resulted in a head wound that required a transfer to an acute care hospital. (refer to tag A0145)

Based on policy and procedure review, document review, and interview, the Hospital failed to ensure verification of nursing licenses for contracted nurses, failed to ensure contract agency staff adhered to hospital policy, failed to ensure drugs and biologicals were administered in accordance with physician orders and failed to ensure nursing care plans were current and up to date.

The cumulative effects of this deficient practice have the potential for the 37 current inpatients receiving care in the hospital and any future patient admitted to the hospital to experience a deterioration in their condition with possible negative outcomes related to nursing assessment, administration of medications, and care.

Findings Include:

1. The hospital failed to ensure the procedure for verification of nursing licenses for licensed nurses not employed by the hospital was implemented. (Refer to tag A0394)

2. The nursing director failed to ensure contract agency nursing staff adhered to the policies and procedures of the hospital and provided for the adequate supervision and evaluation of all nursing personnel. (Refer to tag A0398)

3. The hospital failed to ensure drugs and biologicals were administered in accordance with physician orders. (Refer to tag A0405)

4. The hospital failed to ensure the patient's nursing care plan was kept current and updated/revised after patient falls. (Refer to tag A0396)

Based on policy reviews, document reviews, observations, and interviews, the hospital failed to have an active hospital-wide program for the surveillance, prevention, and control of healthcare-acquired infections, and other infectious diseases, and for the optimization of antibiotic use through stewardship, as evidenced by failing to employ methods for preventing and controlling the transmission of infections within the hospital, and other institutions and settings.

The cumulative effects of this deficient practice resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death) situation.

The surveyor notified the hospital that an IJ existed on 10/29/20 at 9:30 AM, related to 42 CFR 482.42 Condition of Participation: Infection Prevention and Control and Antibiotic Stewardship. The hospital submitted a credible removal plan and removed the IJ on 10/30/20 at 6:00 PM. The removal plan included the following:

1. The patient was moved to a private room on 10/28/20 at approximately 2:15 PM.
2. The nurse was provided re-education on 01/28/20 at 1:42 PM on the policy and process for Contact Isolation.
3. A physician order for isolation was entered into the electronic medical record on 10/28/20 at 1:54 PM.
4. Staff confirmed all patients on isolation precautions were isolated in a private room.
5. A stat urinalysis was ordered on the patient's roommate. The patient is being monitored for signs and symptoms of infection each shift, and a urine culture will be obtained if indicated.
6. The patient's care plan was updated to include contact isolation requirements.
7. The Medical Director, Chief Clinical Officer, and Chief executive Officer reviewed the Infection Control policies and procedures on 10/29/20. It was determined to adopt the Infection Control policies and procedures from the parent organization, to include the policies:
"Infection Reporting" - includes a statement that the Infection Preventionist (IP) is notified of positive culture results upon receipt and the IP is responsible to ensure results are reviewed and appropriate action taken related to the issue identified.
"Infection Surveillance"
"Transmission-Based Precautions"
"Culture and Sensitivity Lab results" - includes a statement that the Infection Preventionist (IP) is notified of positive culture results upon receipt and the IP is responsible to ensure results are reviewed and appropriate action taken related to the issue identified.
"Isolation Precautions"
"MDRO Infection"
8. The Recover-Care Infection Control Policies and Procedures were presented to an Ad Hoc Governing Board committee on 10/29/20 with the adoption approved at 12:15 PM. Revisions to policy "Infection Reporting" was approved by the Governing Board on 10/29/20 at 8:20 PM. Revisions to policies "Infection Reporting," "Infection Surveillance," and "Culture and Sensitivity Lab results" were approved by the Governing Board on 10/30/20 at 9:20 AM. Copies of the Infection Control Policy and Procedure manual were placed as reference at the Nurses' Stations on 10/29/20.
9. An isolation Kardex will be implemented and utilized for all patients in Transmission-Based Precautions. It will outline the Transmission-Based precautions specific to the patient with the required type of personal protective equipment (PPE) to utilize as well as recommendations for precautions to take for patient care.
10. Training for all staff will begin 10/29/20 and will continue until 100% of staff providing care in the hospital are trained. It will be completed prior to the start of each shift. No staff member will be allowed to work until this training is completed.
11. The Infection Preventionist (IP) is a registered nurse (RN). She is scheduled to complete Infection Control training as part of the on-boarding training for all new hire Infection Control practitioners. She will complete the "Nursing Home Infection Preventionist" training provided by the Centers for Disease Control and Prevention (CDC) and produced in collaboration with CMS (Centers for Medicare and Medicaid Services). Anticipated completion date is 11/02/20. Until the course is completed, the Regional Nurse Consultant for the corporation has been and remains available to answer questions and guide the Infection Preventionist with any questions. The regional Nurse Consultant is a registered nurse and has successfully completed the CDC "Nursing Home Infection Preventionist Training Course" in July 2019.
12. The IP will be responsible for monitoring this plan of removal. She will complete rounding on a daily basis Monday through Friday which will include the following areas of review: hand hygiene, glove use, isolation set up, and isolation processes. The IP will educate the House Supervisor/Charge Nurse regarding how to complete the Infection Control rounds and will be responsible for complete rounding on weekends. Results of these daily rounds will be reviewed during the Interdisciplinary Clinical review meeting conducted daily Monday through Friday. The rounding will be completed daily for 4 weeks and then weekly thereafter.
13. The IP will complete audits to ensure policy and process for reporting of positive culture results is followed. These audits will be conducted daily for 2 weeks, and weekly for 4 weeks. Results of audits will be presented to the QAPI (quality assessment and performance improvement) committee for their review, recommendations, and oversight of activity.
14. Any employee found to be out of compliance with adherence to facility infection control policies and procedures will be provided Just In Time training that outlines policy requirements.

Findings Include:

1. The hospital failed to ensure the person employed as the Infection Control Officer was qualified through education, special training experience, or certification in infection prevention and control. (Refer to tag A0748 and A0770)

2. The hospital failed to have a system in place for early identification and management of infectious organisms that can be resistant to commonly used antibiotic. (Refer to tags A0749 and A0770)

3. The hospital failed to ensure a patient with a MDRO (multi-drug resistant organism) had a private room or cohorted the patient with another patient with the same organism. (Refer to tag A0749)

4. The hospital failed to ensure all staff were aware that a patient had tested positive for a MDRO and all staff followed contact precautions when they had contact with the patient's environment. (Refer to tag A0749)

5. The hospital failed to obtain a physician's order per hospital policy to place a patient on contact precautions even though there was a sign on the patient's door and gowns and gloves for use. (Refer to tag A0749)

6. The hospital failed to develop and implement a process for the infection preventionist to receive notice of all infections for review, analysis, and investigation immediately upon the staff's receipt of positive lab results. (Refer to tags A0749 and A0770)

Based on policy review, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting effecting three of four patient who are at risk for falls (Patient 1, Patient 3, Patient 4). This deficient practice had the potential to affect the current 37 patients and any future patient admitted to the hospital, placing them at greater risk for injury from falls.


Findings Include:


Review of the hospital policy titled, "Client Rights & Confidentiality," effective 12/13/92 and revised 01/12/13, showed patients had the right to "receive care in a safe setting and be free from all forms of mental and physical abuse and harassment. . ."

Review of the policy titled, "Fall Prevention and Management Program," effective 10/11/07 and revised 01/08/19, showed, "Upon admission, patients are assured of assessment of their risk for falls; manipulation of the environment to prevent falls; and appropriate management of those who experience a fall. . . Registered Nurses [RN] and licensed Practical Nurses [LPN] are responsible for implementation and oversight of individualized patients fall prevention care as follows: a. Implementing the Fall Prevention and Management Interventions (Attachment A) specific to determined fall risk level; and implementing the Fall Prevention Standard (Attachment B) for patients upon admission; b. Determining risk for fall and establishing appropriate prioritized patient need / nursing diagnosis related to fall risk in the patient plan of care; c. Reassessing residents for change in fall risks when the patient is transferred, a change in condition occurs or following a fall episode; d. Supervising ancillary personnel in delivering safe and personalized care; e. Evaluating patients plan of care and revising as needed; f. Collaborating with the interdisciplinary team in the prevention of falls. . . 2. Prevention Interventions/Strategies a. Environmental Safety - All staff will implement interventions to create a safe environment. b. The Fall Prevention Standard will be implemented to reduce medication-related fall risk factors. . . d. An interdisciplinary care plan will be initiated to include the Fall Prevention and Management Interventions (Attachment A)."

Review of "Attachment A: Fall Prevention and Management Interventions Standard Interventions" showed a list of interventions that included . . . Bed in lowest position with wheels locked. . ." Additional Interventions showed a list of interventions that included ". . . Bed alarm Wheelchair alarm, Bedside mat, High-Low bed, Bedside mattress or mattresses . . ."

Review of "Attachment B Fall Prevention Standard," . . . showed a list of standards that included ". . . Instruct the patient to call for help before getting out of bed. . . Bed in lowest position with wheels locked. . . Patients with Mental Status Changes Instruct the patient not to get up without help, reinforce every shift and with each transfer. Minimize distractions. Observe activity frequently. Use bed and wheelchair alarms when indicated. . ."

Review of the "IRF-Morse fall Scale," (a rapid and simple method of assessing a patient's likelihood of falling), showed high risk is "45 and higher Moderate Risk 25-44 Low Risk 0-24." Further review showed the assessment included history of falling, secondary diagnosis, ambulatory aid, intravenous or intravenous access, gait, and mental status.


1. Review of Patient 1's electronic medical record, (EMR), with Staff I Licensed Practical Nurse (LPN) navigating the EMR, showed Patient 1 was admitted on 06/26/20 and discharged on 07/01/20. Patient 1's diagnosis was "diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter."

Review of Patient 1's "Progress Notes," showed documentation by Staff W LPN on 07/01/20 at 1:33 PM showed "pt. [patient] bed alarm heard going off. Life Skills arrived to room first to find pt. [patient] laying on the floor. This nurse and CNA [certified nursing assistant] arrived and found pt. [patient] laying on floor on her right side, with her head laying on the bed frame. Pt [patient] had significant amount of bleeding from right side of head, temple area. Pt [patient] was helped into a more comfortable position and place head on pillow with pressure applied to site of injury with a towel. VS [vital signs] taken at this time. This nurse called Physician and decision was made to send to hospital for further evaluation. . . EMS [emergency medical service] arrived and assessed pt. Pt left facility and was transported via EMS to [name of acute care hospital]."

Review of Patient 1's care plan showed a focus area was "Risk for falls as evidenced by: [patient] confusion with recent injury Date Initiated: 05/27/20. . ." Further review showed, "Interventions/Tasks" included "Maintain hazard free environment Date Initiated: 05/27/20 Place patient near nurses' station while update Initiated: 05/27/20."

Review of Patient 1's "Physical Therapy Transitional Evaluation and Plan of Treatment," signed by the physical therapist on 06/03/20, showed "Precautions" included ". . . safety/fall precautions, high fall risk, decreased balance, bed alarm, chair alarm. . ."

Review of Patient 1's "Treatment Administration Record," (TAR), showed, "Apply bed/chair alarms for safety. Check placement and function every shift Start Date 05/26/20," and "Low Bed / Fall Precautions every shift for fall Prevention Start date 05/27/20," were checked as done by Staff W LPN on 07/01/20 for the 6:00 am to 6:00 PM shift.

During an interview on 10/27/20 at 10:10 AM, Staff F Director of Quality and Risk Manager, (DQRM), stated that she had completed the hospital's self-report of the fall incident on 07/01/20 for Patient 1. She stated, "I don't know if [a low bed and mat on the floor] it's necessarily a requirement, they should have been in place in my opinion."

During an interview on 10/28/20 at 8:56 AM, Staff Q, Recreational Therapist (RT), stated that she was the first staff to arrive to Patient 1's room once she heard the bed alarm go off. Staff Q, stated that the bed was not in a low position and was positioned about 3 feet off the ground. She stated there was no bed mat on the floor, and she does not think there was a mat in the room, "from my immediate memory." She stated for patients with a fall risk mats on the floor were supposed to be in place, but she does not know about the position the bed needs to be. She stated if the patient isn't in bed, they're supposed to be at the nurses' station. She stated her head was "kind of on the edge of the bed resting on the frame." She stated Patient 1 told her she wanted to get up, so Staff Q, told Patient 1, she would go tell the nurse. Staff Q stated that she instructed Patient 1 to remain in bed until Staff Q returned, but Patient 1 evidently didn't do that.



2. Review of Patient 3's "Admission Record," showed he was admitted on 09/30/20 and was a current inpatient. Further review showed his diagnosis was "unspecified intracranial injury without loss of consciousness, initial encounter."

Review of an incident report documented by Staff X, RN on 10/08/20 at 4:37 AM, for Patient 3, showed, "Pt [patient] alarm was sounding. Nursing staff went to his room and pt [patient] was sitting on the floor with his legs crossed. . .Pt [patient] c/o [complained of] mild pain in right knee. Pt [patient] has 2 old scabs intact on right knee. Pt [able to stand with minimal assist and transfer to wheelchair. Pt reports he crawled out of bed and needed to go to the bathroom. After pt [patient] was assisted to wheelchair, pt [patient] was assisted to the bathroom and pt [patient] was continent of urine. . ." Further review showed "Immediate Action Taken Description: Fall mats placed at bedside. . ."

Review of Patient 3's "Physical Therapy PT Evaluation & Plan of Treatment," dated 10/01/20 at 4:46 PM, showed Patient 3 "is at high fall risk due to balance deficit, gross motor coordination deficit, impulsive with mobility, and decreased insight into personal fall risk."

Review of Patient 3's care plan, showed a focus of "Risk for falls as evidenced by impulsiveness Date initiated 10/01/20" and "Interventions Task" of "Devices used: (Specify: Bed alarm, chair alarm, side rails, fall mat next to bed, gait belt, low bed, wheel chair, grab bars) Date initiated: 10/01/20 . . . Maintain hazard free environment Date initiated: 10/01/20 Place patient near nurses station while up Date initiated: 10/01/20. . ."

There was no documented evidence that the care plan was revised after the fall occurred on 10/08/20.

Review of Patient 3's "IRF-Morse fall Scale" dated 10/07/20 at 8:35 PM, showed his score was 30, which was moderate risk.

Review of Patient 3's EMR, with Staff I LPN navigating the EMR, verified no documented evidence that showed checks had been performed for low bed position, bed/chair alarms checked for proper function, and that bed mats were on the floor, all interventions included in Patient 3's care plan.

During an interview on 10/28/20 at 10:30 AM, Staff I, LPN stated that review of Patient 3's nurses' notes and TAR showed no evidence that checks had been performed for low bed position, bed/chair alarms checked for proper function, or that bed mats were on the floor. She stated these interventions were included in Patient 3's care plan and not in place.


3. Review of Patient 4's EMR, with Staff I LPN navigating the EMR, showed Patient 4 was admitted on 03/12/20 and was a current inpatient. Further review showed her diagnosis was "traumatic subdural hemorrhage (bleeding that causes pressure on the brain) with loss of consciousness of unspecified duration, initial encounter."

Review of incident reports related to Patient 4, showed the following falls:

08/01/20 at 8:49 AM, by Staff Y, LPN - "Staff was in another pt's [patient] room when we came out, we found this pt [patient] crawling across the floor in front of the nurse's station with her w/c [wheelchair] behind her."

08/30/20 at 5:51 PM by Staff Z LPN - "Unsure what happened as this nurse was in a patient's room with other staff member tending to them. . . Minor Injury - Skin Discoloration. . ."

09/25/20 at 9:55 AM by Staff AA RN - "Patient stated that she had a fall last night, then she said it happened this morning in her room. We (this writer and CNA) were in her room when she went down on her knee and tried to go to bed. She has a superficial abrasion on her right forearm. Pt stated: "I was going to my bed I fell and hit my head."

Review of Patient 4's care plan with the focus of "Risk for fall as evidenced by: Impulsivity, history of multiple falls Date initiated: 04/08/20," showed "Interventions/Tasks" included "Devices used: (Specify: wheelchair, low bed, mat on floor) Date initiated: 12/31/20 [date is incorrect] Devices used: (Specify: Broda chair (chair that tilts back), low bed, mat on floor) Date initiated: 04/08/20 Devices used: (Specify: Bed alarm, chair alarm, side rails, fall mat next to bed, gait belt, low bed, wheel chair, walker, seizure pads, grab bars, . . . Date initiated: 04/08/20 . . . Maintain hazard free environment Date initiated: 04/08/20 Place patient near nurses station while up Date initiated: 04/08/20. . ."

There was no documented evidence that care plan was revised after each documented fall.

During an interview on 10/28/20 at 11:00 AM, Staff I, LPN stated that review of the nurses' notes, located under the "Progress Notes" tab and the TAR, located under the "Orders" tab, showed no evidence that checks had been performed by the nursing staff for proper function of bed and chair alarms, that the bed was in the lowest position, or that mats were placed on the floor next to the bed, which were all interventions included in Patient 4's care plan. She further stated the care plan was not revised after the falls documented above.

During an interview on 10/29/20 at 12:23 PM, Staff F DQRM stated, at the Quality Assessment and Performance Improvement (QAPI) meeting, they discuss number of falls, the actual number of falls, the number of falls per patient days, the types of falls, if injury or non-injury, if injury is minor or major, and if the patient has had repeat falls. She stated corrective action has included educating staff to follow the fall management program in place. She stated she doesn't think she has anything documented to show revisions to any action taken regarding falls.

During an interview on 10/29/20 at 12:43 PM, Staff K Medical Director, stated they review each fall that has occurred on the morning meeting with all department heads each weekday. She stated they're discussed on a daily basis and falls over the weekend are discussed on Monday. Staff K, Medical Director, stated she reviews the patient's record from the transferring hospital and looks at the fall risk. She stated she understands "if the nurse isn't documenting the assessment for fall risk interventions, one can't say it was done." She stated that care plans should be revised when falls occur.

During an interview on 10/29/20 at 4:10 PM, Staff F, DQRM, was asked if a root cause analysis for falls had been completed? Staff F, DQRM, stated that there had been "no formal root cause analysis for falls." She stated that everything done related to falls "has been done verbally." Staff F, DQRM stated that 90 falls in four months (June, July, August, and September 2020) warranted a root cause analysis. She stated she felt that by addressing falls on the clinical call held each day immediately, would provide quicker action to prevent the patient from having a recurrent fall

Based on policy review, record review, and interview, the hospital failed to ensure a patient was free from neglect for one (Patient 1) of four patient falls reviewed from a sample of 12 patients. This deficient practice had the potential to affect the current 37 patients and any future patient admitted to the hospital at greater risk for injury from falls.

Findings Include:

Review of the policy titled, "Patient Rights," effective 01/10/91 and revised 03/17/09, showed patients had the right to "be free from mental and physical abuse, to be free from chemical and (except in emergencies) physical restraints. . ."

Review of the hospital policy titled, "Abuse Neglect Exploitation," effective 01/12/17, showed neglect was defined as, "The failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish or emotional distress. . ."

Review of Patient 1's electronic medical record (EMR), with Staff I Licensed Practical Nurse (LPN) navigating the EMR, showed Patient 1 was admitted on 06/26/20 and discharged on 07/01/20. Patient 1's diagnosis was "diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter."

Review of Patient 1's "Progress Notes," showed documentation by Staff W, LPN on 07/01/20 at 1:33 PM, "pt [patient] bed alarm heard going off. Life Skills arrived to room first to find pt [patient] laying on the floor. This nurse and CNA [certified nursing assistant] arrived and found pt laying on floor on her right side, with her head laying on the bed frame. Pt [patient] had significant amount of bleeding from right side of head, temple area. Pt [patient] was helped into a more comfortable position and place head on pillow with pressure applied to site of injury with a towel. VS [vital signs] taken at this time. This nurse called Physician and decision was made to send to hospital for further evaluation. . . EMS [emergency medical service] arrived and assessed pt. Pt left facility and was transported via EMS to [name of acute care hospital]."

Review of Patient 1's care plan showed a focus area was "Risk for falls as evidenced by: pt confusion with recent injury Date Initiated: 05/27/20. . ." Further review showed "Interventions/Tasks" included "Maintain hazard free environment Date Initiated: 05/27/20 Place patient near nurses' station while update Initiated: 05/27/20."

Review of Patient 1's "Physical Therapy Transitional Evaluation and Plan of Treatment" signed by the physical therapist on 06/03/20, showed "Precautions" included ". . . safety/fall precautions, high fall risk, decreased balance, bed alarm, chair alarm. . ."

Review of Patient 1's "Treatment Administration Record," (TAR) showed, "Apply bed/chair alarms for safety. Check placement and function every shift Start Date 05/26/20," and "Low Bed / Fall Precautions every shift for fall Prevention Start date 05/27/20," were checked as done by Staff W LPN on 07/01/20 for the 6:00 AM to 6:00 PM shift.

The hospital failed to ensure Patient 1's bed was in the lowest position, and failed to ensure a mat was on the floor next to the patient's bed as ordered by the physician, and/or included as interventions on the patient's care plan.

Review of Patient 1's Computerized Tomography (CT) performed at the acute care hospital on 07/01/20 at 3:01 PM showed, "Impression: 1. Small acute subarachnoid hemorrhage in the left ambient cistern. 2. Presumed chronic small vessel ischemic disease and mild cerebral atrophy. 3. Right frontal scalp swelling."

Review of "Procedures" performed at the acute care hospital on 07/01/20 showed Patient 1 had a right parietal scalp wound one centimeter in length that was repaired with two skin staples.


During an interview on 10/27/20 at 10:05 AM, Staff F, Director of Quality and Risk Manager, (DQRM), stated that she had completed the hospital's self-report of the fall incident on 07/01/20 for Patient 1. She stated, "I don't know if [a low bed and mat on the floor] it's necessarily a requirement, they should have been in place in my opinion."


During an interview on 10/28/20 at 8:56 AM, Staff Q, Recreational Therapist (RT), stated that she was the first staff to arrive to Patient 1's room once she heard the bed alarm go off. Staff Q, stated that the bed was not in a low position and was positioned about 3 feet off the ground. She stated there was no bed mat on the floor, and she does not think there was a mat in the room, "from my immediate memory." She stated for patients with a fall risk mats on the floor were supposed to be in place, but she does not know about the position the bed needs to be. She stated if the patient isn't in bed, they're supposed to be at the nurses' station. She stated her head was "kind of on the edge of the bed resting on the frame." She stated Patient 1 told her she wanted to get up, so Staff Q, told Patient 1, she would go tell the nurse. Staff Q stated that she instructed Patient 1 to remain in bed until Staff Q returned, but Patient 1 evidently didn't do that

Based on policy review, document review, and interview, the hospital failed to ensure its quality assessment and performance improvement (QAPI) program included an ongoing program that showed measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors and measure, analyze causes, and track adverse patient events, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. The hospital had 90 patient falls from 06/01/20 to 09/30/20 and failed to perform a root cause analysis to analyze the causes and implement corrective action. This deficient practice has the potential to place the 37 current inpatients and any future patient admitted to the hospital, who were at increased risk for falls, at greater risk for harm and injury.

Findings Include:

Review of the hospital's "Quality Assurance Performance Improvement Plan," revised 06/16/20, showed the purpose of the plan was to "create an environment which promotes the continuing examination and assessment of the delivery of client care services." Further review showed "Each service and department will be responsible for identifying and resolving client care trends, as well as pursuing opportunities to improve client care." Review of the section titled "Implementation of the QAPI Plan" showed "each team/department establishes clinical aspects of care that will be monitored and evaluated. Identify Aspects of care/Service: Each service/department/team identifies high priority functions, processes, treatments and activities (both clinical and non-clinical) having the greatest impact on quality of patient care. Identification of indicators: Each service/department/tea, through interdepartmental or intradepartmental teams, identifies indicators that objectively measure important aspects of care. . . Collect and Organize Data: The data is collected, organized and compared to its trigger mechanism. . . When data results demonstrate that the established level of criteria has been exceeded, or when opportunities for improvement exist, the problem will be analyzed. . . Action plans will be developed . . . and enacted to solve the problems or take the opportunity to improve the process and/or outcome. . . Findings of monitoring and evaluation activities, with action plans and follow-up evaluation, shall be taken to the QAPI Committee, Administration, General Medical Staff Committee and Governing Body. . ."


During an interview on 10/29/20 at 12:23 PM, Staff F DQRM stated she's responsible for QAPI. She stated they discuss at each morning meeting held each weekday with department heads and administration, the actual number of falls, the number of falls per patient days, the types of falls, if there was injury or non-injury, if the injury is minor or major, and if the patient has had repeat falls. She stated corrective action has included educating staff to follow the fall management program in place. She stated she doesn't think she has anything documented to show revisions to any action taken. Staff F DQRM was asked to present data collected, analysis for causes, and corrective action taken related to falls.

During an interview on 10/29/20 at 4:10 PM, Staff F DQRM was asked if a root cause analysis had been done for falls. She stated there has been "no formal root cause analysis for falls." She stated everything that's been done related to falls has been done verbally. When asked if 90 falls in four months (06/01/20 through 09/30/20), would have warranted a root cause analysis, Staff F DQRM stated "yes." She stated she felt that by addressing falls on the clinical call each morning immediately, it would provide quicker action to prevent the patient from having a recurrent fall.

No QAPI data presented was provided, including analysis of data and corrective action plans related to patient falls prior to the end of the survey on 10/20/20 at 6:20 PM.

Based on policy review, document review, and interviews, the hospital failed to implement a procedure for verification of nursing licenses for licensed nurses not employed by the hospital. One of three contracted nurses' personnel files (Staff D Licensed Practical Nurse - LPN) from a total of six personnel files reviewed showed no documented evidence of a valid and current nursing license. This deficient practice had the potential to affect the care provided by contract agency nursing staff for the current 37 inpatients and any future patient admitted to the hospital.

Findings Include:

Review of the hospital policy titled, "VII. Licensed Nurse Credentialing and License Verification," effective 12/01/19, showed ". . . 6. Licensed nurses not employed by our facility but who may perform services at our facility are credentialed through the agency in which they represent. . . Agencies are required to provide licensing information upon request from the Administrator, or his/her designee. . ."

Review of Staff D LPN's personnel file showed no documented evidence of a valid and current nursing license.

Review of the contract/agreement between the healthcare staffing agency and the hospital showed that the staffing agency's responsibilities included, ". . . 4. Provide clients, upon request, with documentation of the skills and qualifications of assigned personnel, either via e-mail or facsimile. 5. Instruct all THPs [temporary healthcare professional] to always carry on their person an original license, evidence of current CPR [cardiopulmonary resuscitation] and any applicable specialty certifications, for immediate client inspection. . ."

During an interview on 10/29/20 at 10:20 AM, Staff V Director of Human Resources, (HR), stated that she does not have any responsibility for the contracted nurses. She stated the staffing coordinator enters the contracted employees into the system (where they can clock in and clock out). Staff V stated that it was her understanding that Staff B, Chief Clinical Officer (CCO) and Staff C, Infection Control Officer (ICO) get the information from the contract agency. She stated, after reviewing Staff D LPN's personnel file, the file did not contain evidence of a valid and current nursing license.

During an interview on 10/29/20 at 11:05 AM, Staff B, CCO, with Staff ICO present, stated that she interviews contract agency staff and assures they have a valid and current nursing license. Staff B, CCO began employment with the hospital one month ago.

Based on policy review, record review, and interview, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient. The RN failed to write verbal physician orders for labs and failed to ensure the nursing staff implemented the lab orders for one of six patient records reviewed (Patient 9) for physician verbal orders and implementation of physician orders from a total of 12 sampled patients. This deficient practice had the potential to affect the 37 current inpatients and any future patient admitted to the hospital. This failure put patients at risk for medications errors causing adverse reactions.

Findings Include:

Review of the hospital policy titled, "Nursing Documentation In The Medical record," effective 09/15/89 and revised 05/09/19, showed "RNs and LPN's [licensed practical nurses] may document telephone orders in the patient's record. The physician will sign these orders within 48 hours. . ."

Review of Patient 9's electronic medical record (EMR), with Staff I LPN navigating the EMR, showed Patient 9 was admitted on 05/01/20 with a diagnosis of "hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following nontraumatic intracerebral hemorrhage (brain bleed) affecting right dominant side."

Review of an incident for Patient 9, presented by Staff F Director of Quality and Risk Manager, (DQRM), showed on 07/17/20 at 8:30 AM Staff O RN documented she had given Patient 9 another patient's medication. Further review showed "I immediately notified Staff J Physician (MD). Staff J MD stated to hold his scheduled Coreg 12.5 mg [milligrams], Norvasc 10 mg, Remeron 15 mg today. Check Bmp [basic metabolic panel] today. BP [blood pressure Q [every] 1 hour x [times] 4." Review of the entire EMR, specifically under the tab "Orders," with Staff I LPN navigating the EMR, showed no documented evidence a physician's verbal order was documented by Staff O RN for orders received to hold Coreg, Norvasc, and Remeron on 07/17/20 and to draw a BMP on 09/17/20.

Staff O RN was on medical leave and not available for interview per Staff A Chief Executive Officer, (CEO), on 10/28/20 at 7:40 AM.

During an interview on 10/28/20 at 9:49 AM, Staff I, LPN, stated that she reviewed the EMR under the "Orders" tab, and there was no physician order documented by Staff O RN for the medications to be held and for the BMP to be done on 07/17/20 as written in the incident report. She stated there was no documented evidence that a BMP was drawn on 07/17/20, and there was no documentation that the physician was notified that the lab was not drawn.

During an interview on 10/29/20 at 8:10 am, Staff A CEO offered no explanation related to the failure of staff to document deficiencies related to medication administration, failure to document physician's verbal orders, and failure to obtain lab draws as ordered.

Based on policy review, record reviews, and interviews, the hospital failed to ensure the patient's nursing care plan was kept current and updated/revised after patient falls for four of four patient records reviewed for falls (Patient 1, Patient 2, Patient 3, Patient 4) from a sample of 12 patient records. This deficient practice had the potential to affect the current 37 patients admitted to the hospital and any future patient admitted to the hospital. Failure to update and revise patient care plans put patients at risk for falls and injury.

Findings Include:

Review of the policy titled, "Nursing Care Plans," effective 09/15/89 and revised 05/09/19, showed it is the policy of the hospital "to have a plan of care, individualized for each patient, initiated within 12 hours of admission utilizing the nursing process." Further review showed "Each nurse assigned to the patient will evaluate the plan of care and when changes are noted, the nurse will document such changes in the care plan."

1. Review of Patient 1's electronic medical record (EMR) showed Patient 1 was admitted on 06/26/20 and discharged on 07/01/20. Patient 1's diagnosis was "diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter."

Review of Patient 1's care plan showed a focus area was, "Risk for falls as evidenced by: pt [patient] confusion with recent injury Date Initiated: 05/27/20. . .," Further review showed, "Interventions/Tasks," included "Maintain hazard free environment," Date Initiated: 05/27/20, "Place patient near nurses station while up," date Initiated: 05/27/20.

Review of Patient 1's "Physical Therapy Transitional Evaluation and Plan of Treatment" signed by the physical therapist on 06/03/20, provided by Staff A, Chief Executive Officer, (CEO), due to the therapy notes being a part of a different computer system, showed "Precautions" included ". . . safety/fall precautions, high fall risk, decreased balance, bed alarm, chair alarm. . ."

Review of Patient 1's "Treatment Administration Record" (TAR) located under the "Orders" tab in the EMR showed, "Apply bed/chair alarms for safety. Check placement and function every shift Start Date 05/26/20," and "Low Bed / Fall Precautions every shift for fall Prevention Start date 05/27/20."

There was no documented evidence Patient 1's nursing care plan was updated to add the fall precaution interventions of bed alarm, chair alarm, and low bed position.

During an interview on 10/27/20 at 11:15 AM, Staff I LPN stated that Patient 1's nursing care plan in the EMR showed no evidence that the nursing care plan had been updated to add the interventions of bed alarm, chair alarm, and low bed position.

2. Review of Patient 2's electronic medical record (EMR) showed Patient 2 was admitted on 09/04/20 with a diagnosis of "diffuse traumatic brain injury with loss of consciousness of unspecified duration, initial encounter."

Review of Patient 2's "Progress Notes," located under the "Progress Notes" tab in the EMR, showed he had a fall on 09/10/20 and 10/10/20.

Review of Patient 2's nursing care plan, located under the "Care Plan" tab, showed a focus area was "Risk for falls as evidenced by impulsive, impaired gait Date initiated: 09/10/20." Further review showed, "Interventions/Tasks," included, "Devices used: (Specify: Bed alarm, chair alarm, side rails, fall mat next to bed, gait belt, low bed, wheelchair Date initiated: 09/10/20 . . ." Further review showed the care plan was revised on 09/10/20 after the "non-injury fall" to add "Maintain hazard free environment." There was no documented evidence nursing staff revised Patient 2's care plan after the fall on 10/10/20.

During an interview on 10/27/20 at 1:00 PM, Staff I LPN stated that the EMR does not show any evidence that nursing staff revised Patient 2's nursing care plan after the fall on 10/10/20.

3. Review of Patient 3's "Admission Record," located under the "Profile" tab, showed he was admitted on 09/30/20 and was a current inpatient. Further review showed his diagnosis was "unspecified intracranial injury without loss of consciousness, initial encounter."

Review of a report provided for review by Staff F, Director of Quality and Risk Manager, (DQRM), showed Patient 3 had a fall on 10/08/27 at 4:37 AM.

Review of Patient 3's care plan, documented under the "Care Plan" tab in the EMR, showed a focus of, "Risk for falls as evidenced by impulsiveness," date initiated 10/01/20, and "Interventions Task," of "Devices used: (Specify: Bed alarm, chair alarm, side rails, fall mat next to bed, gait belt, low bed, wheel chair, grab bars), Date initiated: 10/01/20 . . . Maintain hazard free environment Date initiated: 10/01/20 Place patient near nurses station while up Date initiated: 10/01/20. . ." There was no documented evidence that nursing staff revised the care plan after the fall occurred on 10/08/20.

During an interview on 10/28/20 at 10:30 AM, Staff I LPN stated that the EMR did not show any evidence that nursing staff revised Patient 3's nursing care plan after the fall on 10/08/27.

4. Review of Patient 4's EMR showed the "Admission Record," located under the "Profile" tab, showed Patient 4 was admitted on 03/12/20, and was a current inpatient. Further review showed her diagnosis was "traumatic subdural hemorrhage (brain bleed) with loss of consciousness of unspecified duration, initial encounter."

Review of reports related to Patient 4 presented by Staff F DQRM, showed Patient 4 had falls on 08/01/20, 08/30/20, and 09/25/20.

Review of Patient 4's care plan with the focus of, "Risk for fall as evidenced by: Impulsivity, history of multiple falls Date initiated: 04/08/20," showed "Interventions/Tasks" included "Devices used: (Specify: wheelchair, low bed, mat on floor) Date initiated: 12/31/20 [date is incorrect] Devices used: (Specify: Broda chair, low bed, mat on floor) Date initiated: 04/08/20 Devices used: (Specify: Bed alarm, chair alarm, side rails, fall mat next to bed, gait belt, low bed, wheel chair, walker, seizure pads, grab bars, . . . Date initiated: 04/08/20 . . . Maintain hazard free environment Date initiated: 04/08/20 Place patient near nurses station while up Date initiated: 04/08/20. . ." The EMR did not show any evidence that nursing staff revised the care plan after each of the documented falls.

During an interview on 10/28/20 at 11:00 AM, Staff I LPN stated that the EMR did not show any evidence that nursing staff revised Patient 4's nursing care plan after the falls on 08/01/20, 08/30/20, and 09/25/20.

Based on document review and interviews, the nursing director failed to ensure contract agency nursing staff adhered to the policies and procedures of the hospital and provided for the adequate supervision and evaluation of all nursing personnel. Three of three contract agency nursing staff personnel files reviewed (Staff D Licensed Practical Nurse (LPN), Staff N LPN, and Staff P LPN) from a sample of six personnel files reviewed for orientation and competency evaluations showed no documented evidence of orientation and training on hospital policies and procedures, and no documented evidence of an evaluation of competence conducted by a hospital-employed registered nurse (RN). This deficient practice had the potential to affect the care provided by contract agency nursing staff to the current 37 inpatients and any future patient admitted to the hospital. This failure put patients at risk for receiving substandard nursing care.

Findings Include:

Review of the contract/agreement between the healthcare staffing agency and the hospital showed that the client's/hospital's responsibilities included ". . . 2. Provide orientation which, at minimum, includes the review of policies and procedures regarding the medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA [Occupational Safety and Health Administration] and EMR [electronic medical record]/Charting (if applicable). . . 5. Assist [name of contract staffing agency] with the periodic evaluation (no less than annually) of THP [temporary healthcare professional] job performance. . ."

Review of the personnel files of Staff D LPN, Staff N LPN, and Staff P LPN, showed each LPN was contracted through the healthcare staffing agency. Further review showed no documented evidence that orientation and training had been provided by the hospital on policies and procedures regarding the medication administration, documentation procedures, patient rights, Infection Prevention, and Fire and Safety, OSHA, and EMR/Charting. There was no documented evidence that Staff D LPN, Staff N LPN, and Staff P LPN had been evaluated for competency by a hospital-employed RN.

During a telephone interview on 10/28/20 at 2:25 PM, Staff N LPN stated she had no training when she appeared for her first assignment on 09/15/20. She stated she had experience with the computer system used by the hospital but not with the Pyxis (medication dispensing system). Staff N LPN stated the nurse who gave her report spent about 10 minutes to get her logins to the computer system and the Pyxis, and to give report. She stated she had no training on the hospital's policies and procedures, medication administration, documentation procedures, patient rights, infection prevention, fire and safety, and EMR/charting.

During an interview on 10/29/20 at 11:05 AM, Staff B Chief Clinical Officer (CCO) and Staff C Infection Control Officer (ICO) present, Staff B CCO, and Staff C IC, stated they did not have any further documentation to show that the above-listed contract agency had completed orientation and demonstrated competency evaluation.

Based on policy review, document reviews, record reviews, and interviews, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders for six of six patient records reviewed (Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 10) for medication errors from a sample of 12 patients. This deficient practice had the potential to affect the 37 current inpatients and any future patient admitted to the hospital putting them at risk for medication errors with adverse drug reaction.

Findings Include:

Review of the hospital policy titled "Administration of Medication," effective March 2011 and revised October 2013, showed "Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices and only by persons legally authorized to do so. . ." Further review showed "Medications are administered in accordance with written orders of the prescriber. . . Patients are identified before medication is administered using at least two patient identifiers. Methods of identification may include a. Check identification band b. Verify with the patient his/her full-name and date of birth. C. Verify patient identification with other hospital personnel. Note: the patient's room number or physical location is not used as an identifier. . . Medications supplied for one patient are never administered to another patient. . ."


1. Review of Patient 5's "Discharge Summary," located under the "Progress Notes" tab in the electronic medical record (EMR), showed Patient 5 was admitted on 01/23/20 with a diagnosis of traumatic brain injury and discharged on 03/19/20.

Review of Patient 5's "Orders Admission Medication Verification and Order Form," contained in the paper copy of the medical record showed a physician order from Staff M Physician (MD) was signed by the registered nurse (RN on 01/23/20 at 8:20 PM and included a list of 20 medications. Some of the medications listed included ". . . 2. Solatol 80 mg [milligram] tab [tablet] 1 tab Q [every] 12 [hours] per G [gastrostomy] tube [given to treat irregular heartbeats] 3. Simvastatin 20 mg 1 tab HS [at bedtime] Comments: sub [substitute] Atorvastatin 10 mg HS [medication used to lower cholesterol levels in the bloodstream] 4. Hydralazine 10 mg 1 tab tid [three times a day] [medication works by relaxing the muscles in the blood vessels to help them dilate (widen) which lowers blood pressure] . . . 6. Amlodipine [Norvasc] 5 mg 1 tab BID [twice a day] [used with or without other medications to treat high blood pressure] . . . 9. Oxycodone 5 mg tab 1 -2 tab Q 4 [hours] prn [as needed] pain 6-10 [on pain scale] . . ." Further review of the order sheet showed a handwritten note of "This page was not written correctly & [and] has been changed med [medication error]."

Review of Patient 5's medical record showed an order from Staff M, MD on 01/25/20 at 9:39 PM to "1 d/c [discontinue] Solatol (med error) 2 d/c Lipitor (med error) 3 d/c hydralazine (med error) . . . 5 d/c Norvasc (med error) 6 d/c Oxycodone IR (med error) 7 Stat EKG 12-lead (done already) . . . DC [discontinue] Lisinopril. Further review showed an order from Staff M, MD on 01/25/20 at 12:40 AM to ". . . 4 NS [Normal saline] 1000 ml (1 L) [milliliters 1 liter] x [times] 2 bolus 5 Place PVC [peripheral vascular catheter] 6 NS 1 L run @ [at] 125 ml/hr [milliliters per hour].

Review of Patient 5's Medication Administration Record (MAR) showed Solatol 80 mg was administered on 01/25/20 at 8:00 AM, Hydralazine 10 mg was administered on 01/25/20 at 8:00 AM and 12:00 PM, and Norvasc 5 mg was administered on 01/25/20 at 8:00 AM.

Review of Patient 5's "Post Admission Assessment/History and Physical", dictated by Staff K Medical Director on 01/24/20 at 11:12 AM showed "Current Medications" included "2. Solatol 80 mg per PEG q 12 hours 3. Atorvastatin 10 mg per PEG q. h.s. [hours sleep] 4. Hydralazine 10 mg per PEG t.i.d. . . . 6. Amlodipine 5 mg per PEG twice daily. . .. 13. OxyIR 5 mg to 10 mg per PEG q 4 hours p.r.n. [per request as needed]."

Staff L, LPN, documented medications to be discontinued Solatol, Lipitor, Hydralazine, Norvasc, and Oxycodone medications due to medication error per "Nurse's Notes" dated 01/25/20 at 11:40 PM.

During an interview on 10/28/20 at 7:40 AM, Staff A Chief Executive Officer (CEO) stated Staff L LPN was no longer employed, and Staff M MD had resigned.

During an interview on 10/28/20 at 2:10 PM, Staff J MD stated, "just blood pressure and heart rate would have been affected [with the medications given in error for Patient 5] and sounds like they gave IV [intravenous] fluids for that."

2. Review of Patient 6's "Admission Record", contained under the "Profile" tab in the EMR, showed Patient 6 was admitted on 03/15/20 with a diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following unspecified cerebrovascular disease (stroke) affecting right dominant side."

Review of Patient 6's "Progress notes", located under the "Progress Notes" tab in the EMR; showed Staff N LPN documented 09/15/20 at 3:48 AM showed "It was brought to this nurse attention at approximately 2200 [10:00 PM] that Tm [room] 401 HS [at bedtime] meds were removed from the Pixus [sic] system and administered via G-tube to Rm 311. [Patient 6] received Flomax [relaxes the muscles in the prostate and bladder neck, making it easier to urinate], Seroquel [antipsychotic medicine that works by changing the actions of chemicals in the brain], Gabapentin [anti-epileptic drug, also called an anticonvulsant, that affects chemicals and nerves in the body that are involved in the cause of seizures and some types of pain], Amantadine HCL [hydrochloride] [antiviral medicine that blocks the actions of viruses in the body], Ascorbic Acid [used to treat and prevent vitamin C deficiency], calcium/Vit [vitamin] D [helps strengthen bones], Divalproex Sodium 750 mg [used in adults to prevent migraine headaches, or to treat manic episodes related to bipolar disorder (manic depression)], Lexapro [antidepressant] and Pepcid [works by decreasing the amount of acid the stomach produces and used to treat and prevent ulcers in the stomach and intestines] in error. . . This nurse notified RN in charge who notified Director. Physician on call was contacted and reported all medications given in error. Orders received. . ."

During a telephone interview on 10/28/20 at 2:35 PM, Staff N LPN stated that the day of the medication error for Patient 6 was her first day working at the hospital. She stated she did not realize she had made an error until another nurse asked where her patient's medications were. Staff N LPN stated she got her login that day for the Pyxis system (medication dispensing system). She stated the MAR and the Pyxis are not in the same room, and you have a "baggie" to put medications in when you remove them from the Pyxis. She stated after you select the medications, you must go to the MAR to verify the medications. Staff N LPN stated there were two patients with the same first name, and she selected the wrong patient's night medications. She stated she didn't verify Patient 6's last name correctly. Staff N LPN stated she also verified the medications in the MAR for the wrong patient also.

3. Review of Patient 7's "Admission Record", contained under the "Profile" tab in the EMR, showed Patient 7 was admitted on 08/04/20 with a diagnosis of anoxic (lack of oxygen) brain damage, not elsewhere classified."

Review of Patient 7's EMR showed a physician's order, located under the "Orders" tab in the EMR, for Buspirone HCL tablet "5 mg give 1 tablet by mouth three times a day for anxiety."

Review of a report presented by Staff F Director of Quality and Risk Manager (DQRM), showed on 08/12/20 the nurse documented "This nurse was informed by the CNA that there was a medication left in the clean linen area. The patient's name was on the medication cup. Buspirone was the name of the medication on the label. She informed me that it was in her pocket at that moment and showed me it was in a glove. I did not think about taking it until I realized I needed to destroy the pill and at 0825 [8:25 AM] took the pill from the CNA. The pill was disposed of properly and the incident was appropriately reported. . ."

Review of Patient 7's MAR, located under the "Orders" tab in the EMR, showed that Buspirone was documented as given at 8:00 AM on 08/12/20.

Review of the progress notes for Patient 7 had no documented evidence by the nurse that the Buspirone was not given or that the physician had been notified. Staff I LPN verified this per interview on 10/28/20 at 9:30 AM.

4. Review of Patient 8's "Admission Record", contained under the "Profile" tab in the EMR, showed Patient 8 was admitted on 05/28/20 with a diagnosis of hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side."

Review of Patient 8's "Progress Notes," located under the tab "Progress Notes" in the EMR, showed the nurse documented on 08/25/20 at 11:48 AM that Patient 8 was "having L [left] eye redness and irritation. Flushed eye with saline and notified Staff M MD, who states may flush eye with saline as needed.

Review of Patient 8's physician orders, located under the "Orders" tab, showed an order on 08/03/20 at 10:53 AM to instill five drops of Debrox Solution (Carbamide Peroxide) in both ears two times a day for cerumen buildup "for 3 days 5 drops in affected ear BID x 3 days unless resident has s/s [signs/symptoms] of ear infection: pain, fever, discharge."

Review of a report provided by Staff F DQRM showed Patient 8 "was given his ear drops in his eye and his eye drops in his ear" on 08/25/20 at 6:29 PM.

Review of Patient 8's MAR showed on 08/25/20 he had one drop of Polyethyl Glycol-Propyl Glycol Solution 0.4-0.3% instilled in both eyes for dry eyes at 8:00 am, 12:00 PM, 4:00 PM, and 8:00 PM. There was no documented evidence that Debrox Solution (Carbamide Peroxide) five drops was instilled in both ears two times a day for cerumen buildup.

During an interview on 10/28/20 at 11:30 AM, Staff I LPN, after reviewing Patient 8's progress notes and nurses' notes, both located under the "Progress Notes" tab in the EMR, stated there was no documentation in the EMR of the medication error and that the physician was notified of the error.

5. Review of Patient 9's "Admission Record", contained under the "Profile" tab in the EMR, showed Patient 9 was admitted on 05/01/20 with a diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side."

Review of a report for Patient 9 provided by Staff F, DQRM showed Staff O RN documented "I saw patient self-propelling down hallway this AM, I thought I remembered him as being in room 306-1 [name of another patient] from when I took vitals earlier this AM. I stated "[name of other patient] how are you? I have your meds for you." The patient responded "ok" and then took the medication I gave him. After patient took the medication. I was going into room 306-2 to him to his meds and noticed a patient was lying in bed 306-1 (not the same patient I just gave meds to). I quickly was able to identify that I gave Patient 9 (302-1) the wrong medication. I gave him [other patient's name] medication. Patient was given 306-1's scheduled AM medication 1) Lisinopril 5 mg [used to treat high blood pressure and congestive heart failure in adults] 2) Modafinil 50 mg [reduces extreme sleepiness due to narcolepsy and other sleep disorders] 3) spironolactone 12.5 mg [potassium-sparing diuretic (water pill) that prevents your body from absorbing too much salt and keeps your potassium levels from getting too low] 4) Zoloft 100 mg [antidepressant] 5) Carvedilol 3.125 mg [used to treat heart failure and hypertension]. Patient is currently supposed to take Coreg 12.5 mg, Norvasc 10 mg, Remeron 15 mg, Vit B12, Colace 100 mg, Lactobacillus, Folic Acid, Vit B1 . . . I immediately notified Staff J MD. Staff J MD states to hold his scheduled Coreg 12.5 mg, Norvasc 10 mg, Remeron 15 mg today. Check Bmp today. BP [blood pressure] Q 1 hour x 4."

During an interview on 10/28/20 at 7:40 AM, Staff A Chief Executive Officer (CEO) stated that Staff O RN was on medical leave and not available to be interviewed.

During an interview on 10/28/20 at 9:49 AM, Staff I LPN stated that she reviewed the EMR under the "Orders" tab, and there was no physician order documented by Staff O RN for the medications to be held and for the BMP to be done on 07/17/20 as written in the report. There was no documented evidence that a BMP was drawn on 07/17/20, and there was no documentation that the physician was notified that the lab was not drawn.

Based on policy review, document review, and interview, the hospital failed to ensure an individual, who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body as the infection preventionist/infection control professional. Staff C, Infection Preventionist (IP), had no documented evidence of education, training, experience, or certification in infection prevention and control, and there was no documented evidence the governing body had appointed her. This failure had the potential to affect the ability to prevent and control the transmission of infections within the hospital that could result in negative outcomes for the 37 current inpatients and any future patient admitted to the hospital.

Findings Include:

Review of the hospital's policy titled, "Infection Prevention and Control Program," implemented 11/01/19, showed ". . . The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. . ." There was no documented evidence that the policy addressed the educational or experience requirements for the Infection Preventionist.

Review of the "Governing Body Meeting" minutes for 01/16/20, 03/31/20, 06/18/20, and 10/15/20, provided by Staff A, Chief Executive Officer (CEO), showed no documented evidence that Staff C, IP had been approved as the Infection Preventionist.

Review of Staff C IP's personnel file showed she was hired on 09/23/20. There was no documented evidence of training, prior work experience, or certification in infection prevention and control.

During an interview on 10/28/20 at 3:20 PM, Staff C, IP stated she "never had an infection control-specific position before and had no further education in infection control other than what any employee would receive." When the federal regulation was reviewed with Staff C IP, she stated that she would agree that she didn't meet the regulatory requirement to be an infection preventionist/infection control professional.

Based on policy reviews, observations, document reviews, and interviews, the hospital failed to ensure the infection prevention and control program employed methods for preventing and controlling the transmission of infections within the hospital as evidenced by:

1. Failing to have a system in place for early identification and management of infectious organisms that can be resistant to commonly used antibiotic.

2. Failing to ensure a patient (Patient 12) with a MDRO (multi-drug resistant organism) had a private room or cohorted the patient with another patient with the same organism.

3. Failing to ensure all staff were aware that a patient had tested positive for a MDRO and all staff followed contact precautions when they had contact with the patient's environment.

4. Failing to obtain a physician's order per hospital policy to place a patient on contact precautions even though there was a sign on the patient's door and gowns and gloves for use.

5. Failing to develop and implement a process for the infection preventionist to receive notice of all infections for review, analysis, and investigation immediately upon the staff's receipt of positive lab results.

6. Failing to ensure the person employed as the Infection Control Officer was qualified through education, special training experience, or certification in infection prevention and control.

7. Failing to ensure gym mats, tilt table mat, and Broda chair leather was free of tears to allow for proper disinfection between patient use.

8. Failing to ensure soiled linen was placed in plastic liners and placed in linen hampers rather than on the floor and the red infectious waste bin was covered in the Soiled Linen Room.

9. Failing to ensure Staff E, Housekeeper (HK) changed gloves and performed hand hygiene between tasks when cleaning/disinfecting a patient room.

10. Failing to ensure a nurse allowed the appropriate two minute wet time when disinfecting a glucometer and changed gloves and performed hand hygiene before disinfecting a glucometer in preparation for storage.

11. Failing to ensure a nurse performed hand hygiene after removing gloves before touching the medication cart.

12. Failing to ensure contract/agency staff received education on the hospital's infection control policies and procedures and on COVID-19.

These deficient practices had the potential to result in transmission of infectious organisms to the 37 current inpatients, any future patient admitted to the hospital, and hospital staff.
The cumulative effects of these deficient practices resulted in an Immediate Jeopardy (IJ) (a situation in which entity noncompliance has placed the health and safety of patients in its care at risk for serious injury, serious harm, serious impairment or death) situation that was called on 10/29/20 at 9:30 AM.


Findings Include:


Review of the hospital policy titled, "Isolation Precautions: Standard and Transmission Based," effective 11/01/90 and revised 12/10/14, showed ". . .1. Contact precautions are required for patients who are known or suspected to have infection caused by germs that travel by direct contact. Contact is the most common form of infection transmission. It can occur from direct skin-to-skin contact or by indirect contact through the patients environment. 2. Obtain order from physician for isolation and obtain a private room. If private room is not available, patient may only be placed in room with another patient with the same infection but no other infection with the exception of C-difficile [clostridium difficile]. 3. Indicated Isolation for the client on the 24 hour report. 4. Place stop sign alert and Transmission Based Precautions instructions on client's door indicating all visitors need to check at the nurses station prior to entering the room. 5. Place fully stocked isolation caddy on outside of door. (Caddy will contain gloves, masks, protective eyewear, shoe covers, hair covers, gowns and plastic bags.) 6. Gloves will be worn when entering the room. Gloves will be changed when contact is made with infective material. Hands will be washed immediately after glove removal. Care will be taken to not contaminate hands prior to leaving patient's room. Gowns will be worn if contact with the patient or contaminated surfaces is expected. . ."

Review of the hospital policy titled "IX. Culture and Sensitivity Lab Results," implemented 03/01/20, showed ". . . 1. Laboratory testing, including culture and sensitivity testing, shall be in accordance with physician/practitioner orders and current standards of practice. . . 4. Procedures for monitoring and reporting of culture and sensitivity lab results: a. The nurse receiving the order for culture and sensitivity testing shall communicate the order on the 24-hour shift report and report to the oncoming nurse. b. The 24-hour shift report may be used by nursing staff, nurse leaders, and the Infection Preventionist to identify residents who have pending lab results. Monitor for receipt of lab results and take action as needed when results have not been received in a timely manner (i.e. [that is] within 48-72 hours). This includes monitoring for receipt of culture results obtained elsewhere, such as ER [emergency room], clinic, or specialist's office. c. Follow facility policy for filing lab results. d. Report positive culture results to physician/practitioner, including the antibiotics to which the identified pathogen is susceptible. E. Report antibiotic resistance immediately to physician/practitioner. F. Document physician/practitioner notification and response. 5. The Infection Preventionist is responsible for monitoring culture results and tracking infections/antibiotic use in accordance with the facility's infection prevention and control/antibiotic stewardship program(s). This may be accomplished through logs or other tracking mechanisms. There was no documented evidence that the policy required the nurse to notify the Infection Preventionist immediately upon receipt of a positive culture result.

Review of the hospital policy titled "VI. Infection Reporting," implemented 11/01/19, showed ". . . 4. New orders for antibiotics or new lab orders, such as to obtain cultures, will be notated on the 24 hour shift report. 5. Positive culture results will be reported to the physician. 6. The nurse noting orders for isolation will communicate the type of isolation ordered for the resident, and room number, to all departments, the Director of Nursing, Administrator, and the Infection Preventionist. 7. Transmission-based isolation precautions will be noted with a sign on the resident's door for the duration the resident is on isolation. 8. The Infection Preventionist will review medical records and lab reports. Any infection or communicable disease that is a reportable disease will be reported to public health authorities. 9. The Infection Preventionist will report findings of surveillance activities, including at a minimum, incidence rates and types of infections, to the QAA [quality assessment assurance] committee, physicians, and other appropriate staff.


Review of Patient 12's electronic medical record (EMR) showed he was admitted on 06/19/20 with a diagnosis of traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter.

Review of a "Urine Culture" report, presented by Staff A, Chief Executive Officer (CEO) on 10/29/20 at 8:10 AM showed a "draw date" of 10/20/20 and "results reported" date of 10/23/20 at 11:32 AM. Further review of the report showed notation of "10/23/20 11:30 AM methicillin-resistant staphylococcus aureus (MRSA) called to [name of Staff D Licensed Practical Nurse (LPN)] at 11:30 10/23/20," and a "Colony Count > [greater than] 100,000 / ML" [per milliliter]. Further review showed a hand-written note of "10/24/20 2120 [9:20 pm] notified [name of nurse practitioner] no new orders d/t [due to] colony count. Review [with] Dr. on Monday" with initials only of the person making the documentation. Further review showed a hand-written note below the above documentation with different handwriting of "D/C [discontinue] Levaquin Linezolid 600 mg 1 po [by mouth] bid x 10d." [twice a day for 10 days]

Review of the "Urine Culture Final - Approved 10/23/20 11:30 AM," presented by Staff A, CEO on 10/29/20 at 8:10 AM, showed a hand-written note of "Started Linezolid 600 mg for MRSA in urine. On 10/26/20 - Contact Precaution" with no documented evidence of initials or a signature of the person who wrote the note.

Observation on the Brain Injury Unit on 10/28/20 at 11:55 AM showed a sign on the patient door of Room 302 that read "Contact Precautions," and isolation gowns and gloves were hanging on the caddy attached to the door. When the surveyor asked Staff D, LPN, who was being observed during a medication pass, if one of the patients in Room 302 was on contact precautions, she looked at her report sheet and stated she didn't see anything documented for either patient about contact precautions. Staff D, LPN did not leave to check both patients' records (Patient 9 and Patient 12) before entering Room 302. Staff D, LPN entered Room 302 and instilled GenTeal Tears one drop to Patient 9's right eye.

During an interview on 10/28/20 at 12:25 PM, Staff A, CEO stated Staff B, Chief Clinical Officer (CCO) and Staff C Infection Control Officer (ICO) are charge nurses during the day. She stated both Staff B, CCO and Staff C, ICO stated they knew Patient 12 was on contact precautions. When Staff B, CCO (who was present during this interview) was asked if a patient on contact precautions could be roomed with a patient not on contact precautions, Staff B, CCO stated "no," and she stated, "I didn't know he [Patient 12] had a roommate."

During an interview on 10/28/20 at 12:40 PM, Staff D, LPN stated she got shift report from the night nurse, and the night nurse didn't report that Patient 12 was on contact precautions. Review of Staff D, LPN's report sheet during the interview showed no documentation that Patient 12 was on contact precautions.

During an interview on 10/28/20 at 2:15 PM, Staff A, CEO stated she spoke with Staff K Medical Director, Patient 12's physician, who said Patient 12 was on contact precautions for MRSA in the urine. Staff A, CEO stated contact precautions was initiated, but she's not clear exactly when, but probably either the 26th or the 27th of October. She stated, "per Staff K Medical Director's note I would say the 27th."

During an interview on 10/28/20 at 3:40 PM, Staff B, CCO was asked why she didn't stop the nurse from entering Patient 9's and Patient 12's room when she was standing in the hall during Patient 9's medication pass if she knew Patient 12 was on contact precautions. Staff B, CCO stated she didn't notice the nurse went into the room without a gown, because she was talking in the hall with Staff A, CEO.

During an interview on 10/28/20 at 3:50 PM, Staff C, ICO stated the leadership (department heads) have daily stand-up meetings and infections are reported in that meeting. She stated they are still developing a process for reviewing infections. Staff C, ICO stated lab results are called to the physician by the staff nurse, but the results aren't sent to her.

During an interview on 10/28/20 at 5:20 PM, Staff B, CCO and Staff C, ICO present, Staff B stated, "today we looked in the chart and knew Patient 12 was on contact precautions when I saw the CP [equipment] hanging on the door." Staff A, CEO arrived during the interview and stated Patient 12's lab report came in on 10/26/20, and they didn't have the department head meeting on 10/27/20 and 10/28/20 due to the survey. She stated that's where the infection would have been reported. Staff A, CEO stated she didn't know about Patient 12's MRSA diagnosis until the surveyor identified the issue. Staff C, ICO stated she learned of Patient 12's MRSA diagnosis when the surveyor asked about it today.

During an interview on 10/29/20 at 10:23 AM, Staff D, LPN stated she received the call from the lab on 10/23/20 reporting that Patient 12 had MRSA. She stated she reported it to the RN working with her who told her the physician knew about the lab result, and they were waiting for the sensitivity report. Staff D, LPN stated she reported the result a second time to the RN who told her again the physician knew and was waiting for the sensitivity to determine what antibiotic to give. Staff D, LPN stated she never saw the actual lab result. She stated on 10/28/20 that she told another nurse she had never seen the result from the lab, and the other nurse told her it comes on the fax machine up front [meaning by the receptionist's desk]. Staff D, LPN stated she didn't know that the result came on the fax machine "up front." Staff D, LPN stated she didn't make the connection with Patient 12 when the surveyor asked if Patient 9 or Patient 12 had MRSA during Patient 9's medication pass, because she works "all over the hospital and didn't remember."

During an interview on 10/29/20 at 12:43 PM, Staff K, Medical Director, stated a colony count greater than 100,000 would warrant antibiotics and absolutely contact precautions. She estimated she would have known about the diagnosis earlier in the week, because she was at the hospital on 10/23/20 and 10/24/20. She stated she doesn't follow up on a lab that she doesn't order. Staff K, Medical Director, stated she is Patient 12's attending physician and the internal medicine group manages blood pressure, medications, infections, and antibiotics. She stated she saw the contact precautions caddy on the door Monday 10/26/20, and she wouldn't have looked for an order, because she would have expected that the internal medicine group would have given an order.

During an interview on 10/30/20 at 4:25 PM, Staff A, CEO, stated the number of infections in the past year was 197 from 10/02/19 to 09/30/20. She stated the number was not broken down into healthcare acquired infections and community-acquired infections.


Review of the hospital's policy titled, "Infection Prevention and Control Program," implemented 11/01/19, showed, ". . . The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases. . ." There was no documented evidence that the policy addressed the educational or experience requirements for the Infection Preventionist.

Review of the "Governing Body Meeting Minutes" dated 01/16/20, 03/31/20, 06/18/20, and 10/15/20 lacked any evidence that the Governing Body appointed Staff C as the Infection Control Officer.

Review of Staff C, ICO's personnel file showed a hire date of 09/23/20. The personnel file lacked evidence that Staff C had any training, prior work experience, or certification in infection prevention and control.

During an interview on 10/28/20 at 3:20 PM, Staff C, ICO stated that she never had an infection control-specific position before. She stated she had no further education in infection control other than what any employee would receive. When the federal regulation was reviewed with Staff C ICO, she stated she would agree that she didn't meet the regulation as an infection preventionist/infection control professional.



Review of the policy titled "Cleaning & [and] Disinfecting of Non-Critical reusable Equipment/Items For patients in Hospital," effective 08/25/94 and revised 05/17/17, showed the hospital's policy is to reduce the transmission of microorganisms due to contaminated non-critical reusable equipment/items for patient use." Further review showed a breakdown of the cleaning schedule by day of the week for each nursing unit. There was no documented evidence the therapy gym was included in the schedule.

Review of the "Guidelines for Environmental Infection Control in Healthcare Facilities," shown in "Recommendations of CDC [Centers for Disease Control and Prevention] and the Healthcare Infection Control Practices Advisory Committee (HICPAC)," showed ". . . Maintain upholstered furniture in good repair. . ."

Observation on 10/27/20 at 8:45 AM during a tour of the Acute Rehab Unit, with Staff A, CEO and Staff B, CCO present, showed the therapy gym had two large blue mats covering a low table where patients can sit for exercise therapy with multiple holes/tears with exposed padding that prevented the ability to disinfect the mats. Further observation in the hall outside the therapy gym showed there was a tilt table on wheels that had tears in the leather with exposed padding and a Broda chair with tears in the headrest with exposed padding that prevented the ability to disinfect the table and chair between patient use.


Review of the hospital policy titled, " I. Infection Prevention and Control Program," effective 11/01/19, showed ". . .Soiled linen shall be collected at the bedside and placed in a linen bag. When the task is complete, the bag shall be closed securely and placed in the soiled utility room. . . "
Review of the hospital policy titled, "Infection Control: General Policies," effective 09/15/89 and revised 12/10/15, showed ". . . Trash cans shall be lined with disposable plastic bags and disposed of at the end of each shift or more frequently as necessary. . ." there was no documented evidence that the trash can should be covered.

Observation on 10/27/20 at 8:55 AM in the Soiled Linen room on the Acute Rehab Unit showed a plastic bag on the floor with a bedspread in it. There were two rolling linen hampers in the room without liners in place to hold linen. Further observation showed a red infectious waste bin was uncovered with the cover lying on the floor. This places patients, visitors, and staff at risk for exposure to contaminated linens and infectious materials.

Review of the hospital's policy titled, "Hand Hygiene," effective 09/15/89 and revised 10/11/12, showed the five moments for hand hygiene included "1. Before touching a patient. . . 2. Before clean/aseptic procedure. . . 3. After body fluid exposure risk. . . 4. After touching a patient. . . 5. After touching patient's surroundings. . ."

Observation on 10/27/20 at 9:03 AM on the Brain Injury Unit showed Staff E, HK cleaning Room 305. She exited the room wearing gloves, placed the soiled wash cloth used to clean Room 305 in a plastic bag hanging on the housekeeping cart, got the pad for the dust mop off the housekeeping cart, and attached it to the base of the dust mop with the contaminated gloves used to clean Room 305. Further observation showed Staff E, HK dust mopped the room, placed the dirty dust mop pad on the housekeeping cart, took a broom and dustpan from the cart, and swept the floor outside Room 305. She then removed her gloves and walked to the hand sanitizer mounted on the wall down the hall. Observation showed when the hand sanitizer did not appear when she pressed the unit, Staff E, HK took the cover off the sanitizer unit and repositioned the sanitizer bag. After re-applying the sanitizer cover, Staff E, HK sanitized her hands and walked away. Observation showed Staff E, HK did not return to wipe the sanitizer unit after having touched it with her contaminated hands.

During an interview on 10/27/20 at 9:15 AM, Staff E, HK stated she had cleaned the blinds in Room 305 and dusted the furniture. She stated she then changed her gloves and cleaned the bathroom and toilet. She stated when she exited the room wearing gloves, the gloves were the same gloves she had worn to clean the bathroom and toilet. She stated she did not change her gloves and sanitize her hands before getting cleaning supplies from the housekeeping cart. Staff E, HK stated she should have changed her gloves and performed hand hygiene when she finished cleaning the bathroom and toilet in Room 305. She stated she didn't return to disinfect the hand sanitizer unit that she had touched after removing her gloves and before sanitizing her hands.


Review of the manufacturer's label on the container of "Super Sani-Cloth," the product used to disinfect the glucometer, ". . . To disinfect nonfood contact surfaces only: Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet a full two (2) minutes. . ."

Observation on the Brain Injury Unit in Room 414 on 10/27/20 at 11:45 AM, showed Staff G, RN, performed an Accu-check [test to determine the blood glucose level by fingerstick] on a Patient.

Staff G, RN washed her hands, gloved, and wiped the glucometer with a "Super Sani-Cloth."
The surveyor asked Staff G, RN how long the glucometer had to remain wet, and she stated, "I don't know if it has a specific time, I just wait for it to dry." The surveyor observed Staff G, RN looking at her watch and asked her how long she waited. She stated "it was about a minute. I'd say it's good & dry." Observation showed Staff G, RN cleaned the glucometer and placed it on the same paper towel used since the start of the procedure while wearing the contaminated gloves she used to draw the blood specimen. She then removed her gloves and washed her hands. Staff G, RN placed the glucometer that had been disinfected with contaminated gloved hands in the cart without disinfecting it with clean gloved hands.

During an interview on 10/27/20 at 12:00 PM, Staff G, RN stated she wasn't aware the glucometer had to remain wet for 2 minutes after being wiped with the Sani-Cloth. She stated she knew she had to change gloves before moving to the next task of cleaning the glucometer, but "I got nervous because I was being watched."


Review of the hospital's policy titled "Hand Hygiene," effective 09/15/89 and revised 10/11/12, showed the five moments for hand hygiene included "1. Before touching a patient. . . 2. Before clean/aseptic procedure. . . 3. After body fluid exposure risk. . . 4. After touching a patient. . . 5. After touching patient's surroundings. . ." There was no documented evidence the policy addressed the need for hand hygiene after removing gloves.

Review of the CDC's "Guideline for Hand Hygiene in Health-Care settings," published 10/25/02, showed hands should be decontaminated "after removing gloves."

Observation on 10/28/20 at 11:55 AM showed Staff D, LPN entered Room 302 to instill GenTeal Tears one drop to Patient 9's right eye. She exited the room wearing the gloves she used to instill the eye drop and touched the medication cart with her contaminated gloved hands.

During an interview on 10/28/20 at 12:10 PM, Staff D, LPN stated she didn't have sanitizer on her when asked about touching the medication cart with contaminated gloved hands (had earlier observed that Staff D, LPN used hand sanitizer that was in the bottom drawer of the medication cart). She asked the surveyor "should I keep it on me?" referring to hand sanitizer.



Review of the hospital's policy titled "Coronavirus Surveillance," implemented 03/10/20, "Novel Coronavirus Prevention and Response," implemented 03/29/20 and revised 05/01/20, "Coronavirus Testing," implemented 09/01/20," and "COVID-19 Reporting," with no documented effective date, showed no documented evidence that any of the policies addressed training of staff employed by the hospital and contract/agency staff on COVID-19.

Review of the personnel files of Staff D, LPN, Staff N, LPN and Staff Patient, LPN showed each LPN was contracted through an agency. Further review showed no documented evidence that orientation and training had been provided by the hospital on policies and procedures regarding COVID-19.

During an interview on 10/29/20 at 11:05 AM, Staff B, CCO and Staff C, ICO present and Staff B stated they had no further documentation to present for orientation and competency evaluation of the above-listed contract agency staff.

During an interview on 10/30/20 at 11:13 AM, Staff A, CEO stated they had not provided education on COVID-19 to the agency nurses.

Based on policy review, document review, and interviews, the hospital's governing body failed to ensure systems were in place for the tracking of all infection control surveillance, prevention, and control in order to demonstrate the implementation, success, and sustainability of such activities by having a non-qualified Infection Preventionist. This failure led to a delay in identifying one patient (Patient 12) with a multi-drug resistant organism (MDRO) placing Patient 12's roommate (Patient 9) and staff at risk from an infectious organism because Patient 12 was not placed in isolation and staff were not using appropriate personal protective equipment (gloves, gowns, masks) and had the potential to affect the ability to prevent and control the transmission of infections within the hospital that could result in negative outcomes for the 37 current inpatients, any future patient admitted to the hospital, and hospital staff.

Findings Include:

Review of the hospital's policy titled, "Infection Prevention and Control Program," implemented 11/01/19, showed, "...The designated Infection Preventionist serves as a consultant to our staff on infectious diseases, resident room placement, implementing isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases..." There was no documented evidence that the policy addressed the educational or experience requirements for the Infection Preventionist.

Review of the "Governing Body Meeting Minutes" dated 01/16/20, 03/31/20, 06/18/20, and 10/15/20 lacked any evidence that the Governing Body appointed Staff C as the Infection Control Officer (ICO).

Review of Staff C, ICO's personnel file showed a hire date of 09/23/20. The personnel file lacked evidence that Staff C had any training, prior work experience, or certification in infection prevention and control.

During an interview on 10/28/20 at 3:20 PM, Staff C, ICO stated that she never had an infection control-specific position before. She stated she had no further education in infection control other than what any employee would receive. When the federal regulation was reviewed with Staff C, ICO, she stated she would agree that she didn't meet the regulation as an infection preventionist/infection control professional.

The hospital lacked a consistent process to identify infections and to notify the ICO. The hospital holds daily department head meetings on the weekdays to discuss current issues including any newly identified infections.

During an interview on 10/28/20 at 5:20 PM, Staff B, CCO (with Staff C, ICO present) stated, "today we looked in the chart and knew Patient 12 was on contact precautions when I saw the CP [equipment] hanging on the door." Staff A, CEO arrived during the interview and stated Patient 12's lab report came in on 10/26/20, and they didn't have the department head meeting on 10/27/20 and 10/28/20 due to the survey. She stated that's where the infection would have been reported. Staff A, CEO stated she didn't know about Patient 12's methicillin resistant staphylococcus aureus (MRSA - an antibiotic resistant organism) diagnosis until the surveyor identified the issue. Staff C, ICO stated she learned of Patient 12's MRSA diagnosis when the surveyor asked about it today.