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A. Based on observation and staff interview it was determined the facility failed to ensure dietary services was furnished in accordance with applicable State regulations. The dietary department failed to retain a sample of potentially hazardous foods from the menu of each meal under adequate refrigeration for a period of at least twenty-four (24) hours after serving. This failure has the potential to adversely affect all patients at the facility.

Findings include:

A tour of the dietary service department was conducted on 4/4/22 at 2:35 p.m. During the tour, no samples of potentially hazardous foods were located in the refrigerator.

During the above tour on 4/4/22 at 2:35 p.m., the Manager of Dietary Services stated samples of potentially hazardous foods are kept from Monday to Monday but concurred no samples had been kept from the breakfast and lunch menus for 4/4/22.

B. Based on document review and staff interview it was determined the facility failed to ensure laboratory (lab) personnel received in-service training appropriate to the type and complexity of the services offered on a regularly scheduled basis in accordance with applicable State regulations. This failure has the potential to adversely affect all patients receiving lab services at the facility.

Findings include:

A review of the in-service training for all lab personnel revealed no in-services have been completed since 2020.

An interview was conducted with the Director of Nursing (DON)/Quality on 4/6/22 at 12:30 p.m. The DON concurred the last in-service for lab personnel was completed in 2020. The DON stated, "There is no policy on training."

A. Based on a document review and staff interview it was determined the facility failed to ensure nursing staff was following the policy for maintaining crash cart checks, to ensure a working crash cart was available in the Emergency Department (ED). This failure has the potential to adversely affect all patients who may present to the facility with a life-threatening illness.

Findings include:

A review of the crash cart checklists for the ED was conducted on 4/4/22 at 1:30 p.m. A review of the February 2022 crash cart check list revealed no documentation the crash cart was checked on 2/1, 2/2, 2/3, 2/14, 2/15, 2/16, 2/17, 2/26, 2/27 and 2/28/22. A review of the March 2022 crash cart checklist revealed no documentation the crash cart was checked on 3/1, 3/3, 3/12, 3/13, 3/14, 3/29 and 3/30/22.

A review of the policy titled "Crash Cart," dated 11/2008, revealed in part: "The crash cart is to be checked every night per check off sheet and initialed."

An interview was conducted with staff member #4 on 4/4/22 at approximately 1:35 p.m. Staff member #4 concurred the crash cart was not checked as per policy.

B. Based on observation, document review and staff interview it was determined the facility failed to ensure supplies for patient used in the Emergency Department (ED) had not expired. This failure has the potential to adversely affect all patients who present to the ED for care.

Findings include:

A tour of the ED was conducted on 4/4/22 at 1:30 p.m. with ED staff. During the tour, expired supplies were observed in the ED for patient use: three (3) pediatric oxygen saturation (SPO2) sensors (expired 3/31/21), thirty (30) saline flushes (expired 3/2022), one (1) EZ scrub (expired 11/2021), one (1) EZ scrub (expired 7/2021), one (1) single use Operating Room towel (expired 9/28/21), three (3) pairs of size eight (8) sterile gloves (expired 2/27/22), three (3) pairs of size six (6) sterile gloves (expired 10/27/21), one (1) angiocathlon (expired 2/28/22), one (1) angiocathlon (expired 1/31/22), one (1) transducer cover (expired 11/1/21) and one (1) six (6) by six (6) Proima Minor Procedure Drape sealed in a plastic bag, with the inner wrapping disintegrating.

A review of the policy titled "Supplies," dated 9/2006, stated in part: "Night shift will be responsible for assessing supplies/stock levels on the nursing unit, in the clinics, and in the ER nightly and check expiration dates."

During the tour of the ED on 4/4/22 at 1:30 p.m., the ED staff concurred the supplies for patient use were expired.

Based on document review and staff interview it was determined the facility failed to ensure at least one (1) registered nurse (RN), certified in advanced cardiac life support (ACLS), and experienced in emergency care, was available for all hours that emergency services were provided. This failure has the potential to adversely affect all patients who present to the facility for care in the Emergency Department (ED) with a cardiac emergency.

Findings include:

A review of the ED schedule for January, February, March and April 2022 revealed there was no ACLS trained RN working during the following shifts: 1/30/22 on the a.m. shift, 2/3/22 on the a.m. shift, 2/5 and 2/6/22 on the a.m. shift, 2/8/22 on the a.m. shift, 2/12/22 on the a.m. shift, 2/13/22 on the a.m. and p.m. shifts, 2/14 to 2/16/22 on the p.m. shift, 2/17/22 on the a.m. shift, 2/19/22 on the a.m. shift, 2/22/22 on the a.m. shift, 2/25/22 on the p.m. shift, 2/26/22 on the a.m. and p.m. shifts, 2/27/22 on the a.m. shift, 2/28/22 on the p.m. shift, 3/1/22 on the p.m. shift, 3/2/22 on the a.m. and p.m. shifts, 3/3 to 3/9/22 on the a.m. shift, 3/10 to 3/16/22 on the a.m. and p.m. shifts, 3/17 to 3/23/22 on the a.m. shift, 3/24 to 3/30/22 on the a.m. and p.m. shifts, and 3/31 to 4/5/22 on the a.m. shift.

An interview was conducted with the Director of Nursing (DON)/Quality on 4/6/22 at approximately 11:00 a.m. When asked about a ACLS trained RN working the ED, the DON stated they never required a ACLS RN to be on every shift at the ED. The DON stated they have ACLS RNs working the floor also, but never required. The DON stated they are currently training all ED staff RNs for ACLS.

Based on observation and staff interview it was determined the facility failed to ensure the premises of the facility were clean and orderly. This failure has the potential to adversely affect all patients who present to the facility for care.

Findings include:

A tour of the facility was conducted on 4/4/22 at 11:04 a.m. During the tour of the Respiratory Department, located on the second floor, a garbage can was located to the right front of the registration desk to catch leaking water coming from the ceiling.

Upon arrival to the facility on 4/5/22 at 8:15 a.m., the surveyor conference room, located on the second floor, had a large amount of water located on the floor due to a water leak from the ceiling. The facility previously had a laundry cart in the conference room to catch water from the leaking ceiling.

A tour of the Laboratory (lab) Department, located on the first floor, was conducted on 4/5/22 at 10:15 a.m. Located in the lab department and attached to the ceiling, was a drain pan with a garden hose extending from the drain pan to the dirty sink. The garden hose was attached to the ceiling by zip ties. The garden hose appeared soiled. The drain pan was catching a watery substance and draining in the dirty sink. During the tour, when asked how long the drain pan and garden hose had been attached to the ceiling, staff member #1 stated approximately one (1) and a half years.

An interview was conducted with the Director of Nursing/Quality and the Chief Executive Officer on 4/6/22 at 12:35 p.m. They concurred with the above findings.

Based on observation and staff interview it was determined the dietary service department failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. This failure has the potential to adversely affect all patients at the facility.

Findings include:

An observation of dietetic services meal tray preparation for patients was conducted on 4/6/22 at 11:40 a.m. Two (2) dietary staff put on a pair of clean gloves before preparing the trays. Staff member #2 put a pair of oven mitts over the clean gloves and removed the warmed plates from the oven. Staff member #2 removed the oven mitts and began preparing the food trays. Staff member #2 did not use hand sanitizer or don a pair of clean gloves before preparing the tray for the patients. Staff member #3 did not use hand sanitizer or wash hands before donning a pair of clean gloves to prepare patients trays.

An interview was conducted with the Director of Nursing (DON)/Quality on 4/6/22 at approximately 12:30 p.m. The DON concurred there is no policy for hand hygiene for dietary, but all staff take a training in care learning for hand hygiene. The DON concurred the staff failed to use proper hand hygiene.

Based on document review and staff interview it was determined the facility failed to provide active surveillance and maintain a log of incidents related to infection and communicable diseases. This failure has the potential to adversely affect all patients who present to the facility for care who may come into contact with an infection or communicable disease.

Findings include:

A review of the log for incidents related to infections and communicable diseases revealed no log has been kept since November 2020.

An interview was conducted with the Infection Preventionist (IP) on 4/5/22 at approximately 2:45 p.m. The IP concurred no log has been kept since November 2020 for infections and communicable diseases.