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Based on review of facility documentation, and interview with staff (EMP), it was determined that the facility failed to ensure personnel files for contracted radiology staff, were available and in compliance with State licensure laws.
Findings include:
Request was made on October 6, 2022, at approximately 2:30 PM, with EMP7, for the personnel files of the contracted radiology staff. None provided.
An interview conducted on October 6, 2022, at approximately 2:30 PM, with EMP7, confirmed that contracted staff are utilized for the Radiology Services at the facility.

Based on observations, facility policy and procedures and interviews with staff (PF6), it was determined the facility failed to ensure services performed under a contract are provided in a safe and effective manner.
Observation of the dietary department on October 5, 2022, at 11:31 AM revealed, a missing date/time opened label in the walk-in chiller on the following: one (1), one (1) gallon of whole milk. Further observation of the dietary department's walk in refrigerator revealed missing date/time opened labels on the following: one (1), one (1) gallon of barbeque sauce, two (2), one (1) gallon salsa containers, one (1), one (1) gallon of mayonnaise, and one (1) 48 ounce container of lemon juice. Further observation of the dietary department's walk in refrigerator revealed a container of sliced onions with a best by date of October 2, 2022. Further observation of the dietary department's walk in freezer revealed an open box of hashbrowns with the expiration date of June 22, 2022. Further observation of the dietary department's bread shelves revealed 37 bagged in clear plastic loaves of sliced bread missing labeling that included an expiration date and/or a date/time of when the bread was received by the facility.
Review on October 5, 2022 of facility policy "Food Safety Policies and Standards" revision date: April, 1, 2022, revealed "...All foods must be stored and rotated according to First in First Out (FIFO) principles ...Manufacturer ' s expiration dates must be adhered to ... Refrigerated, ready to eat ...food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened. The date marked may not exceed the manufacturer's use by date ...Food that is required to be date marked must be discarded if it: Exceeds the storage temperature requirement ...Is in a container or package that does not bear a date or day or ...Is inappropriately marked with a date or day that exceeds 7 days ..."

Interview with PF6 on October 5, 2022 at 11:43 AM confirmed there was no date/time opened label on the one (1) gallon of whole milk.
Interview with PF6 on October 5, 2022 at 11:51 AM confirmed the container of sliced onions had a best by date of October 2, 2022.
Interview with PF6 on October 5, 2022 at 11:57 AM confirmed in the walk in freezer there was a box of hashbrowns with an expiration date of June 22, 2022.
Interview with PF6 on October 5, 2022 at 12:01 PM confirmed missing date/time opened labels on the following: one (1), one (1) gallon of barbeque sauce, two (2), one (1) gallon salsa containers, One (1), one (1) gallon of mayonnaise, and one (1), 48 ounce container of lemon juice.
Interview with PF6 on October 5, 2022 at 12:08 AM confirmed there was no expiration date on the bags of bread. Further interview revealed PF6 could not confirm when the bread was received by the facility and would be unable to adhere to first in first out principles.

Based on observation and interview with staff (EMP) it was determined the facility failed to ensure nursing staff were knowledgeable in the operational status check for the automatic external defibrillator (AED).

Findings include:

Review on October 5, 2022, of facility policy "Emergency Equipment Crash Carts, Automated External Defibrillator[name of defibrillator] Use and Care" reviewed June 2022, revealed "Registered Nurses (RN), Licensed Practical Nurse (LPN), Mental Health Technicians (MHT) will be trained to use the [name of defibrillator] during orientation ..."


1.Observation on October 5, 2022, at approximately 10:45 AM of PC 1 nursing unit revealed EMP13 was requested to demonstrate the testing of the AED to enure the AED was operational. Continued observation revealed EMP13 was not able to demonstrate the manufacturers instructions for testing the operational status testing of the AED and was not able to demonstrate how to check the battery.


Interview on October 5, 2000, at approximately 11:00 AM with EMP13 confirmed they were trained on the use of the AED and confirmed the monthly operational status testing is performed on the 11-7 shift. Continued interview confirmed EMP13 did not remember how to perform the AED checks for operational status.


2.Observation on October 6, 2022, at approximately 10:30 AM of D'Arclay nursing unit revealed EMP10 was requested to demonstrate the testing of the AED to enure the AED was operational. Continued observation revealed EMP10 was not able to demonstrate the manufacturers instructions for testing the operational status testing of the AED and was not able to demonstrate how to check the battery.

Interview on October 6, 2022, at approximately 10:30 AM with EMP10 confirmed they were not sure if they performed the testing correctly and confirmed night shift tests the AED.
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Based on observation and interview and interview with staff (EMP) it was determined the facility failed to adopt a policy and procedure for permissible alcohol content in personal care products and acceptable types of alcohol in personnel care products for patient use.

Findings include:
Observation on October 5, 2022, at approximately 11:00 AM of storage room located on nursing unit PC 1 revealed bins containing shaving cream, hair shampoo and conditioner and body lotion. Further observation revealed a list of ingredients that contained a substance identified as alcohol.

In an interview on October 5, 2022, at approximately 11:00 AM with EMP6, the surveyor read the list of ingredients for shaving cream, hair shampoo, conditioner and body lotion to EMP6 that contained an ingredient identified as alcohol listed in the first four ingredients. EMP6 stated "this is embarrassing for an alcohol rehab." Further interview with EMP6 revealed personal care products are not permitted for use if alcohol is listed in the first four ingredients of a product.
A request was made on October 5, 2022, at approximately 11:00 AM to EMP6 for a policy and procedure for the types of alcohol permitted in personal care products used at the facility. None provided.

A request was made on October 5, 2022, at approximately 2:00 PM to EMP7 for a policy and procedure for the types of alcohol permitted in personal care products used at the facility. None provided.

A request was made on October 6, 2022, at approximately 9:30 AM to EMP7 for a policy and procedure for the types of alcohol permitted in personal care products used at the facility. None provided.

Review on October 7, 2022, at approximately 9:15 AM of documents submitted by the facility identified the type of alcohol ingredients for the personal care items currently in use at the facility. Further review revealed the documents were screen shots (pictures taken of a computer screen) from an internet search provider that identified the types of alcohol contained in each of the personal care products.

Interview on October 7, 2022, at approximately 9:20 AM with EMP14 Confirmed the documents provided for the personal care products identified during the survey was not a policy and procedure for the types of alcohol permitted for use at the facility.


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Based on observations, review of facility documentation, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that appropriate treatment addressed the patients' medical diagnosis of Sleep Apnea for 14 days.
Findings include:
Review on October 6, 2022, at approximately 11:20 AM, of MR13, revealed in the history and physical, the patient had a history of Sleep Apnea that required a Bi-Level Positive Airway machine (BiPAP) for treatment. Documentation in the history and physical also noted the patient said that she needed her BiPAP machine from home.
Review on October 6, 2022, at approximately 11:20 AM, of MR13, revealed that the patient was admitted on September 11, 2022. Provider order for the BiPAP was not written until September 25, 2022.
Interview on October 6, 2022, at approximately 11:30 AM, with EMP9, confirmed that the patient had a medical history of Sleep Apnea, the patient was admitted on September 11, 2022, the provider order for BiPAP was written on September 25, 2022.

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to establish a nursing care policy and procedure for the routine check of code cart inventory; failed to establish individualized patient care plans; failed to follow establish policy for patient care assignments; failed to follow establish policy for code cart security; failed to follow established policy for daily code cart checks; failed to ensure staff were knowledgeable in the use of an AED and failed to develop a policy for the types of alcohol and the content of alcohol associated with the patient care use.

A discussion took place with the survey team and the facility's administrative staff (EMP6, EMP7, EMP8, and EMP15) regarding the survey team's concerns related to Nursing Services on October 6, 2022, at approximately 2:30 PM.

Cross reference
482.13(c)(2) Patient Rights: Care in Safe Setting
482.23(a) Organization of Nursing Services
482.23(b)(4) Nursing Care Plan
482.23(b)(5) Patient care Assignments
482.23(b)(6) Supervision of Contract Staff

Based on review of facility documents, observation, and interview with staff (EMP) it was determined the facility failed to ensure a policy and procedure was established for routine code cart inventory review.

Findings include:

A request was made on October 6, 2022, at approximately 2:06 PM to EMP8 for a policy and procedure for guidelines for the routine check of the crash cart contents. None provided.


1.Observation on October 5, 2022, of nursing unit PC 1 facility document "Checklist for Code Carts, Complete Inventory" dated April 26, 2022, revealed code cart inventory was checked on April 26, 2022. Further review revealed no documentation of the contents of the 5-drawer cart.

Interview on October 5, 2022, at approximately 2:25 PM with EMP13 confirmed they were not sure if there was a policy or procedure for routine code cart checks and confirmed "They are done on 11-7 shift, we don't do them."

2.Observation on October 6, 2022, of nursing unit D'Arclay facility document "Checklist for Code Carts, Complete Inventory" dated April 26, 2022, revealed code cart inventory was checked on April 26, 2022, and the contents of each drawer were documented as reviewed. Further review revealed the contents of the five drawers were checked and the following items were expired: Drawer 1- E-Box (emergency medications) no expiration date listed on the document; Drawer 4- 1 box of alcohol pads-expiration 08/2022, glucose strips-expiration 07/2022.

Interview on October 6, 2022, at approximately 10:57 AM with EMP10 confirmed the items in the crash cart were documented as expired and confirmed [they] did not know if the medication box was expired "because pharmacy takes care of that." Further interview confirmed EMP10 did not know if there was policy and procedure for the inventory check or how often the inventory should be checked.

Based on observations, review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to establish individualized patient care plans based on patient needs for one of one medical record (MR13) reviewed on the D'Arclay Inpatient Unit.
Findings include:
Observation on October 6, 2022, at approximately 11:20 AM, of MR13, was admitted on September 11, 2022, with medical history of Sleep Apnea, required a Bi-Level positive airway (BiPAP) machine, while sleeping. Nursing documentation failed to list and address the medical condition of Sleep Apnea in the Nursing Plan of Care.
Review on October 6, 2022, of facility policy and procedure "Nursing Plan of Care", dated June 2021, revealed "It is the policy of Eagleville Hospital to develop a nursing plan of care, treatment, or services that reflects the assessed needs and goals of the patient after the nursing admission assessment has been completed."
Interview on October 6, 2022, at approximately 11:30 AM, with EMP9, confirmed that the patients' medical condition of Sleep Apnea, was not listed in the Nursing Plan of Care.

Based on review of facility documents, policy and procedure and interview with Staff (EMP) it was determined the facility failed to follow its established policy for daily shift assignments for patient care were completed for two of two nursing units. (PC 1 and D'Arclay)


Findings:

Review on October 5, 2022, of facility policy "Assigning Patient Care" revised May 2022, revealed ..."The assignment of nursing care for patients is done by the charge nurse each shift ... Procedure: At the beginning of the scheduled shift, nursing care assignments are defined by the charge nurse and communicated with staff ..."

1.A request was made to EMP4 on October 5, 2022, of nursing unit PC 1 (Patient Care 1) for the daily nursing care assignment for the October 5, 2022, 7-3 shift. None provided.

A request was made to EMP4 on October 5, 2022, of nursing unit PC 1 (Patient Care 1) for the daily nursing care assignment for the October 4, 2022, 3-11 shift. None provided.


Interview on October 5, 2022 with EMP4 at approximately 10:15 AM confirmed there was no documentation daily nursing care assignments were completed for October 5, 2022, 7-3 shift and October 4, 2022, 3-11 shift. Continued interview confirmed daily nursing care assignments are maintained in a binder located in the nurses station for the month.


2.Review on October 6, 2022, at approximately 10:30 AM of the D'Arcly nursing unit revealed a black colored binder that contained the daily assignment sheets for patient care assignments. Further review revealed no documentation daily nursing care assignments were completed for the 7-3 shift and 3-11 shift from October 1, 2022, thru October 6, 2022.


Interview on October 6, 2022, at approximately 10:57 AM with EMP10 confirmed the black binder was used to store the current month's daily nursing care assignment sheets and confirmed there was no documentation nursing care assignments were completed for the 7-3 shift and 3-11 shift from October 1, 2022, thru October 6, 2022.

Based on a review of facility documents, observation, and interview with staff (EMP), it was determined the facility's nursing staff failed to adhere to facility policy for the use and care of emergency equipment.

Findings include:


Review on October 6, 2022, of facility policy "Emergency Equipment Crash Carts, Automated External Defibrillator ... Use and Care" revised June 2022, revealed "... The unit nurse/s are responsible for checking the crash cart daily to ensure oxygen, suction is available ... ambu bag/mask and code cart is locked and intact ... 14) Code Cart is locked with red tag ..."


Observation tour on October 6, 2022, at approximately 10:30 AM of the D'Arclay nursing unit code cart revealed facility document "Crash Cart Lock Numbers." Further review revealed the crash cart was documented as not locked from September 28, 2022, thru October 3, 2022. Continued review of the crash cart document revealed staff documented the following from September 28, 2022, thru October 3, 2022: "Supervisior notified ... email sent to all supervisors"

Interview on October 6, 2022, at approximately 10:57 AM with EMP9 confirmed the the crash cart was documented as not locked from September 28, 2022, thru October 3, 2022. Continued interview confirmed staff documented the nursing supervisor 6 times prior to lock replacement.

Interview on October 6, 2022, at approximately 2:06 PM with EMP8 confirmed nursing supervisors or pharmacy are responsible for replacing the code cart locks after they are notified the lock is missing or needs to be replaced.
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Based on review of facility policy, observation, and interview with staff (EMP) it was determined the facility failed to follow its establish policy for daily code cart checks.


Findings include:

Review on October 6, 2022, of facility policy "Emergency Equipment Crash Carts, Automated External Defibrillator ... Use and Care" revised June 2022, revealed "... The unit nurse/s are responsible for checking the crash cart daily to ensure oxygen, suction is available ... ambu bag/mask and code cart is locked and intact ..."


Observation tour on October 6, 2022, at approximately 10:30 AM of the D'Arclay nursing unit code cart revealed facility document "Crash Cart Lock Numbers" dated February 26, 2022, thru October 6, 2022. Further review revealed no documentation daily code cart checks were documented as completed on February 27, 2022, March 8, 2022, March 12, 2022, March 26, 2022, July 10, 2022, August 13, 2022, August 14, 2022, September 2, 2022, thru September 5, 2022, September 10, 2022, and September 11, 2022.


Interview on October 6, 2022, at approximately 10:57 AM with EMP9 confirmed the the daily crash cart checks were not documented as completed on the above dates.

Based on review of facility policy and procedure, observation, medical record review (MR) and interview with staff (EMP) it was determined the facility failed to ensure staff completed a medication inventory document with the patient at the time of admission for four of four medical records reviewed for patient's bringing their own medications to the facility. (MR3, MR4, MR5, MR32)


Findings include:

Review on October 4, 2022. of facility policy "Patient's Own Medication" reviewed January 2022, revealed "To identify procedure and responsibilities for the safe and appropiate handling of medications brought to Eagleville Hospital by patients ... All medications brought to the Hospital by patients are retrieved by the Admission receptionist or designee and given to the nurse immediately for proper documentation and for secure storage ... When the admissions nurse or MRT (medication reconciliation technician) is available: While the patient is still in admissions, the Admissions Nurse or MRT completes a 'Patient's Own Medication' inventory form in the presence of the patient ... Both nurse or MRT and patient sign the completed forms ... During business hours, an admission nurse or MRT brings the medication to the pharmacy ..."


Observation on October 4, 2022, at approximately 12:30 PM of the Admissions Unit revealed clear plastic bags of medication bottles for each of the patient's in MR3, MR4, MR5 and MR32 in an unlocked metal drawer. The patients presented for admission during regular business hours. Further review revealed the Patient's Own Medication Form was not completed with the inventory of the medication contained in each of the bags. Continued review revealed the form was signed by a signature representing the patients in MR3, MR4, MR5 and MR32 and no documentation of a signature for the nurse or MRT that the form was completed in the presence of the patient.

Interview on October 4, 2022, at approximately 12:45 PM with EMP3 confirmed the patients in MR3, MR4, MR5 and MR32 were admitted to the facility thru the Admissions unit on October 4, 2022, during normal business hours and their medications were collected and placed in the bags with the signature of the patient on a blank Patient's Own Medication Form. EMP3 confirmed the medications for MR3, MR4, MR5 and MR32 were stored in an unlocked drawer. Further interview confirmed the pharmacy collects the bags of patient medications at the end of the day and the inventory form of medications is completed in the pharmacy.

Based on observation and interview with staff (EMP), it was determined the facility failed to maintain a nursing unit in a safe and sanitary condition for patients and staff.

Findings include:

Review on October 5, 2022, of facility policy "Vermin and Pest Control" revised January 2021, revealed "When a rodent or pest is sited, the staff member should place through [sic][online work order] ..."


During an observation tour on October 5, 2022, of nursing unit PC 1 at approximately 11:00 AM revealed a chirping sound in the medication room near the medication refrigerator.


Interview on October 5, 2022, at approximately 11:00 AM with EMP4 confirmed the chirping was from a "cricket that was brought in by a patient and has been here awhile." Further interview confirmed the presence of the insect was not reported thru the online work order system.

Based on review of review of medical records (MR), facility documents, and staff interview (EMP), it was determined the facility failed to ensure patients personal medical equipment, brought into the facility, are inspected to meet electrical safety standards.
Findings include:
A request was made on October 6, 2022, at approximately 11:30 AM to EMP11, for the facility policy regarding electrical safety for medical equipment brought in from outside. None provided.
Review on October 6, 2022, at approximately 11:20 AM, of MR13, revealed that the patient had her personal Bi-Level Positive Airway (BiPAP) machine brought in from home, to use while an inpatient in the D ' Arclay Unit.
Interview on October 6, 2022, at approximately 11:30 AM, with EMP9, confirmed MR13 the patient had her personal BiPAP machine brought in for use in the inpatient unit, D'Arclay.
Interview on October 6, 2022, at approximately 11:45 AM, with EMP11, confirmed that medical equipment brought to facility for patient use is only checked for contraband, but not for electrical safety.

Based on observations, review of facility documentation, Patient Identifier (PT) and interview with staff (EMP), it was determined the facility failed to ensure that a clean and sanitary environment to avoid sources and transmission of infection was maintained.
Findings include:
Observation on October 5, 2022, at approximately 2:15 PM, revealed, in the medication room near the nurses' station on Patient Care Unit I, used oral inhalers and a used nasal spray, for multiple patients, were stored in the same plastic medication bin. One oral inhaler labeled as PT1, a second oral inhaler labeled as PT2, and one nasal spray labeled as PT2.
Review on October 5, 2022, of facility policy and procedures "Storage Requirements For Medication (House-Wide), reviewed January 2022, revealed, "Medications are stored in an orderly and clean environment ... Oral medications, injectable medications, topical/external use only medications: eye and ear preparations are all stored in separate designated areas."
Review on October 5, 2022, of facility policy and procedures "Medication Storage Areas Inspection", reviewed January 2022, revealed, "Medication storage areas are inspected on a routine basis to ensure that medications are safely and properly stored and that storage conditions and security are in compliance with applicable federal and state rules and regulations, professional standards, and hospital policies and procedures for medication storage."
An interview conducted on October 5, 2022, at approximately 2:15 PM with EMP8, confirmed that multiple used oral inhalers and a used nasal spray, for different patients, were stored in the same medication storage bin.



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Observation on October 5, 2022, at approximately 2:15 PM, revealed in the medication room near the nurses' station on Patient Care Unit I, seven used insulin pens from multiple patients were stored in the same plastic medication bin. Two insulin pens labeled as PT3, two insulin pens labeled as PT4, two insulin pens labeled as PT5 and one insulin pen labeled as PT2.

Review on October 5, 2022, of facility policy and procedures "Storage Requirements For Medication (House-Wide), reviewed January 2022, revealed, "Medications are stored in an orderly and clean environments ... Oral medications, injectable medications, topical/external use only medications: eye and ear preparations are all stored in separate designated areas."

An interview conducted on October 5, 2022, at approximately 2:15 PM with EMP8, confirmed that multiple used insulin pens, for different patients, were stored in the same medication storage bin.