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Based on record review and interview the facility failed to ensure that patients or the patients representative received and signed for a completed "An Important Message from Medicare" (IMM) document on admission and within 48 hours of discharge in 1 of 8 Medicare patient records reviewed (Patient # 19) in a total sample of 20.

Findings include:

The facility policy titled "Important Message from Medicare (IM) And Inpatient Discharge Appeal Process (System)" last revised 4/2021 was reviewed. This document revealed "ii. Follow up IM Notice: b. The follow-up IM must be provided to the patient as soon as possible prior to discharge, but no more than 2 days before. If the follow up notice is delivered on the day of discharge, the patient must be given at least 4 hours prior to discharge to consider their rights."



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Patient #19's medical record was reviewed on 08/09/2022 at 12:55 PM. Patient #19 was admitted 06/04/2022 and discharged 06/07/2022 and did not have a documented second IMM completed prior to discharge.

On 08/09/2022 at 12:55 in an interview with Registered Nurse (RN) Case Manager I, when asked if there should have been a second IMM notice given to Patient #19, RN I stated, "Yes, they should have gotten one, because 3 nights in the hospital, should have been given the 3rd day."

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0291 - Emergency Lighting
K-0324 - Cooking Facilities
K-0353 - Sprinkler System - Maintenance And Testing
K-0372 - Smoke Barrier Construction
K-0761 - Maintenance, Inspection & Testing - Doors
K-0916 - Essential Electric System Alarms
K-0918 - Essential Electric System Maintenance and Testing

As a result of these deficiencies, 42 CFR 485.623 Condition of Participation: Physical Plant and Environment was NOT MET.

Based on observation, record reviews and staff interviews, the facility failed to construct, install and maintain the building systems to ensure a physical environment that was safe for patients and staff. The cumulative effects of the environment deficiencies result in the hospital's inability to ensure a safe environment for all patients and staff.

Findings include:

The facility was found to contain the following deficiencies. Refer to the full description at the cited K-tags:

K-0291 - Emergency Lighting
K-0324 - Cooking Facilities
K-0353 - Sprinkler System - Maintenance And Testing
K-0372 - Smoke Barrier Construction
K-0761 - Maintenance, Inspection & Testing - Doors
K-0916 - Essential Electric System Alarms
K-0918 - Essential Electric System Maintenance and Testing

As a result of these deficiencies, 42 CFR 485.623© Life Safety from Fire was NOT MET.

Based on observation, record review and interview the facility failed to provide a safe environment for patients and staff free from potential hazards by failing to secure expired medications on a cart used for training, (Medical-Surgical Unit), and failing to assure prompt access to an emergency eyewash station in 1 of 7 locations with eyewash stations in a patient care area (Emergency Department), in a total sample of 14 patient care areas observed.

Findings include:

Examples on Medical-Surgical Unit:

On 8/8/2022 at 11:15 AM during a tour of the Medical Surgical unit an unlocked red cart was observed in the locked clean utility room. The cart was labeled, "For training purposes only" and contained expired respiratory supplies and expired medications typically used in an emergency situation.

On 8/8/2022 at 11:20 AM in an interview with Medical Surgical Supervisor E, Supervisor E stated that the cart is used for practice for code situations. When asked about access to the Clean Utility room Supervisor E stated that nursing, aides and housekeeping all have access to the room and therefore access to the expired medications. "I see what you are saying, the cart should probably be locked."

Examples in the ED (Emergency Department):

Record review of the facility policy, "Eyewash Station & Shower Policy (ASH)" #10879313 dated 01/2022 revealed, "Procedures:...B. Accessibility to these devices (eyewash stations) is recommended to be within 10 seconds or less travel distance from the hazard area..."

On 8/8/2022 at 11:30 AM during a tour of the ED with ED Supervisor F, an emergency eyewash station was observed to be located in the decontamination room in the attached ambulance garage. In an interview on 8/9/2022 at 2:00 PM, ED Supervisor F stated that medications were prepared in the medication room in the department and that is where a splash could occur. Using a stopwatch Supervisor F was timed walking at a brisk pace from the medication room to the ambulance garage where the eyewash station was located. The time observed was 56 seconds. Supervisor F stated, "I actually walk pretty fast but to wait for the automatic doors to open it took longer than I would have thought."

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Based on observation, interview, and record review, the facility failed to ensure that there were no expired supplies available for patient use in 3 of 14 patient care areas (Laboratory, Emergency Department, Operating Room) in a total sample of 14 patient care areas observed.

Findings include:

Examples in the Laboratory:

On 8/9/2022 at 9:00 AM during a tour of the Laboratory with Phlebotomist G the following supplies were noted to be expired: 30 blue lab tubes for drawing of INR (blood clotting time) with expiration dates of 7/31/2022; 1 "S" Cal (used to calibrate lab equipment) with and expiration date of 7/9/2022 and 2 bottles of "Bleach" tablets. 1 unopened one with a received date of 7/13/2017 and expiration date of 1/2020 and 1 opened bottle dated as opened on 11/10/2018 and an expiration date of 1/2020.

In an interview on 8/9/2022 at 9:00 AM with Phlebotomist G when shown the expired blue top lab tubes and expired "S" Cal Phlebotomist G stated "Yeah they should be thrown out." When asked about the bleach tablets with expiration dates of 2017 and 2020 Phlebotomist G stated "Well we only use them every 3 months. I guess they should have been thrown out."

Examples in the ED (Emergency Department):

On 8/8/2022 at 11:35 AM during a tour of the ED with ED Supervisor F, 3 povidone-iodine 10% swabs (an antiseptic used for skin disinfection) were located in the "Major-Med" room and 3 located in the Trauma room with expiration dates of 8/22.

In an interview on 8/8/2022 at 11:40 AM with ED Supervisor F when asked if the expectation for removal of expired supplies was at the beginning or end of the month on the package stated, "Supplies should be removed at the beginning of the month on the package. We obviously missed these."





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Examples in the Operating Room (OR)/Anesthesia Supply Room:

On 08/09/2022 at 9:00 AM during a tour of the OR/Anesthesia supply room with RN Director of Quality C, 2 disposable Anesthesia Handles (used when placing a patient airway), with expiration dates of 6/12/22 and 7/4/22, 1 oral/nasal tracheal tube tube (a tube placed through the mouth or nose of a patient for an airway) with a use by date of 4/26/22, 25 laryngo-tracheal mucosal atomization device (used to give medication during anesthesia) all with a use by date of 6/3/22 and 1 endotracheal tube inducer (to assist with placing an airway) with a use by date of 6/24/22 were all located in the difficult airway cart located in the anesthesia supply room.

On 08/09/2022 at 9:15 AM in an interview with Certified Registered Nurse Anesthetist (CRNA) Q, when asked who checks for outdated supplies, CRNA Q stated, "It's anesthesia who checks for outdated supplies, expired items are removed. We don't utilize this cart very often and I haven't checked it recently."

Based on interview and record review, the facility failed to provide education and training to the Operating Room (OR) and Emergency Department (ED) staff to effectively treat a potential life-threatening situation in 1 of 1 training programs reviewed.

Findings Include:

Review of facility policy, "Diagnosis and Management of Malignant Hypertermia (Malignant Hyperpyrexia) M.H.," last reviewed 09/20/2020 revealed, "Policy area: Anesthesia....Malignant Hypertermia (M.H>) although rare....has a high mortality rate."

Review of the MH (Malignant Hyperthermia) website https://www.mhaus.org/healthcare-professionals revealed, "The MH crisis is a biochemical chain reactions respons, "triggered" by commonly used general anesthetics and the paralizing agent succinylcholine (a neuromuscular blocker)...death can result....Dantrolene (medication to treat MH) must be available for all anesthetizing locations within 10 minutes of the decision to treate for MH...."

On 08/09/2022 at 2:00 PM in an interview Director of Quality Staff C, when asked about MH drills, stated, "We have no record of MH drills being done within the last 2 years for staff, we have only done the online education with what MH is. It's on the education plan for a skills fair in the fall it shouldn't be just anesthesia."

Based on record review and interview the facility failed to ensure that nursing staff documented a full head to toe assessment on admission and once per shift in 5 of 20 patient records (Pt (Patient) #3, 11, 12, 13, 14) in a total sample of 20 medical records reviewed.

Findings Include:

Review of policy and procedure titled, "Nursing Clinical Documentation Guidelines" last reviewed 04/2022 revealed the following,
1. Documentation will be patient-centered and interdisciplinary, showing the care and treatment delivered and the patients' progress to related nursing interventions, nursing outcomes, and nursing diagnosis in meeting expected outcomes.
a. Clinicians are accountable to document...assessments, evaluations, interventions, plan of care, education, and the patient's response to treatment.

Review of Pt #11's nursing shift assessments revealed the following:
-Shift assessment dated 01/14/2022 at 5:52 PM, revealed there was no documented nursing assessments for Psychosocial, Musculoskeletal, Integumentary (skin), and Peripheral Vascular.
-Shift assessment dated 01/15/2022 at 11:07 PM, revealed there was no documented nursing assessments for Psychosocial, Respiratory, Cardiac, Musculoskeletal, Genitourinary, and Peripheral Vascular.
-Shift assessment dated 01/16/2022 at 9:00 PM, revealed there was no documented nursing assessments for Psychosocial, Musculoskeletal, Integumentary (skin), Gastrointestinal, Genitourinary, and Peripheral Vascular.

Review of Pt #12's nursing shift assessments revealed the following:
-Shift assessment dated 02/24/2022 at 7:45 PM, revealed there was no documented nursing assessments for Neurological, Psychosocial, Respiratory and Musculoskeletal.
-Shift assessment dated 02/25/2022 at 8:30 AM, revealed there was no documented nursing assessments for Psychosocial, Respiratory, Cardiac, Musculoskeletal, Integumentary (skin), Gastrointestinal, and Genitourinary.
-Shift assessment dated 02/25/2022 at 7:45 PM, revealed there was no documented nursing assessments for Neurological and Genitourinary.
-Shift assessment dated 02/27/2022 at 7:24 PM, revealed that there was no documented nursing assessments for Psychosocial, Musculoskeletal, Integumentary, Genitourinary, and Cardiac.
-Shift assessment dated 03/02/2022 at 9:42 PM, revealed that there was no documented nursing assessments for Psychosocial and Respiratory.

Review of Pt #13's nursing shift assessments revealed the following:
-Shift assessment dated 05/22/2022 at 9:56 PM, revealed there was no documented nursing assessments for Psychosocial.

Review of Pt #14's nursing shift assessments revealed the following:
-Shift assessment dated 05/13/2022 at 9:44 PM, revealed there was no documented nursing assessments for Respiratory, Cardiac, Musculoskeletal, Integumentary (skin), Gastrointestinal, Genitourinary, and Peripheral Vascular.

Per interview with Supervisor E on 08/09/2022 at 3:30 PM, Supervisor E stated that staff should be documenting a nursing assessment every shift and the nursing assessment should include all the body systems listed in the nursing assessment flowsheets.



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Patient #3's closed medical record was reviewed on 8/9/2022 at 2:15 PM. Patient #3's admission nursing assessment for visit dated 5/5/2022 had no documented assessment of Genitourinary (GU) or Gastrointestinal (GI) systems.

An interview was conducted with Supervisor E of Medical/Surgical unit on 8/9/2022 at 2:15 PM. When asked the expectation of the review of systems on admission Supervisor E stated "I would expect that all systems were reviewed and they weren't."

Based on observation and record review staff at this facility failed to maintain a sanitary environment free of potential contamination to patients and staff by not adhering to infection prevention policies in 2 of 14 patient care areas (Emergency Department, Dietary), in a total sample of 14 Patient Care areas observed.

Findings include:

Record review of facility policy "Hand Hygiene Policy (System) #11291421 dated 03/2021 revealed, "General Instructions I. Hand hygiene is the single most important means of preventing spread of infection. II. Perform hand hygiene with soap and water or alcohol based hand rub for at least twenty (20) seconds when: ...D. After contact with a patient's intact skin (e.g. when taking a pulse or blood pressure..) G. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. H. After removing gloves.

Examples in the ED (Emergency Department):

On 8/8/2022 at 12:00 PM while on tour in the ED RN L was observed to don a pair of gloves, administer an intravenous medication, adjust the rate on the intravenous, type on the computer in the room, and check the patient's blood pressure without removing gloves or performing hand hygiene.

Examples in Dietary Kitchen:

On 8/9/2022 at 7:35 AM Manager K was observed while preparing trays for hospital patients. It was observed that Supervisor K donned gloves without performing hand hygiene and moved from preparing food to assisting staff at the cash register without removing gloves.

Based on observation, interview and record review, the facility failed to assure safe, sanitary practice in the washing of kitchen utensils and dishes in 1 of 14 patient care areas (Dietary Department), and failed to ensure that food available for patients was dated in 1 of 14 patient care areas (Medical/Surgical floor) in a total sample of 14 patient care areas observed.

Findings include:

Record review of facility policy "Three Compartment Sink" #8969626 dated 12/15/2020 revealed, "Procedure: When using the three-compartment sink proper guidelines need to be followed. Sanitizing sink solution should be checked every time sink is filled for proper sanitizing."

Examples in the Dietary Department:

Record review of the "Dishwasher Temperature Log Month: August" revealed instructions to record the time and the wash cycle temperature and the final rinse temperature after each meal; breakfast, lunch and dinner. Review of the log revealed missing documentation for breakfast on August 1, 2, 2022 and lunch on August 6, 2022. Review of the logs April and May 2022 revealed no documentation on the logs from April 15 - June 22 with the word, "Broke" written on the log for those dates.

On 8/9/2022 at 7:10 AM in an interview with Food Services Manager K, Manager K stated that, "It looks like we missed those dates, (referring to the August 1, 2, 6 dates) we are very short staffed and it must have been forgotten." When asked about the documentation of "Broke" for April 15- June 22, Manager K stated, "The dish machine was out of service so we had to hand wash the dishes in the 3-compartment sink."

On 8/9/2022 at 7:15 AM in an interview with Food Services Manager K, when asked for the documentation of the check of the sanitizing solution when the 3-compartment sink was used for the period of time that the dishwasher was out of service, Manager K stated, "I didn't have a form to use so we didn't do it."

Examples in patient nutrition center on Medical/Surgical floor:

An observation was conducted on 8/8/2022 at 11:00 AM of the refrigerator in the patient nutrition center. There was 2 clear plastic dishes with covers on them, one with grapes in it and one with pudding in it, neither dish had a date on them indicating when they had been put in the refrigerator or when they needed to be discarded.

An interview was conducted with Supervisor E of Medical/Surgical floor on 8/8/2022 at 11:00 AM. When asked how staff would know how old the food in the dishes were and when to get rid of them Supervisor E stated "That's a good question. I guess they wouldn't."

An interview was conducted with Director of Quality C on 8/8/2022 at 12:30 PM. When requested a policy for dating food Director of Quality C stated "We don't have one."



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